Healthcare Provider Details

I. General information

NPI: 1649469743
Provider Name (Legal Business Name): CENTRAL CLINIC, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2007
Last Update Date: 09/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 LANSING AVE
JACKSON MI
49202-3209
US

IV. Provider business mailing address

603 LANSING AVE
JACKSON MI
49202-3209
US

V. Phone/Fax

Practice location:
  • Phone: 517-787-8371
  • Fax: 517-787-2639
Mailing address:
  • Phone: 517-787-8371
  • Fax: 517-787-2639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number4301042822
License Number StateMI

VIII. Authorized Official

Name: DR. DAVID O OLADELE-BANKOLE
Title or Position: OWNER
Credential: MD
Phone: 517-787-8371