Healthcare Provider Details

I. General information

NPI: 1003066440
Provider Name (Legal Business Name): ADEKOYEJO B ADENUGA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2008
Last Update Date: 09/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 KIMOLE LN SUITE B2
ADRIAN MI
49221-1491
US

IV. Provider business mailing address

901 KIMOLE LN SUITE B2
ADRIAN MI
49221-1491
US

V. Phone/Fax

Practice location:
  • Phone: 517-265-1981
  • Fax: 517-263-1001
Mailing address:
  • Phone: 517-265-1981
  • Fax: 517-263-1001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301068655
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: