Healthcare Provider Details

I. General information

NPI: 1740888122
Provider Name (Legal Business Name): MOSOBALAJE I ADEWOLE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2020
Last Update Date: 11/09/2020
Certification Date: 11/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22448 HALLCROFT TRL
SOUTHFIELD MI
48034-5498
US

IV. Provider business mailing address

22448 HALLCROFT TRL
SOUTHFIELD MI
48034-5498
US

V. Phone/Fax

Practice location:
  • Phone: 313-424-8371
  • Fax:
Mailing address:
  • Phone: 313-424-8371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: