Healthcare Provider Details

I. General information

NPI: 1245795236
Provider Name (Legal Business Name): OLUMIDE BABATOPE OGUNWUMI PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2019
Last Update Date: 04/04/2023
Certification Date: 04/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21851 CENTER RIDGE RD STE 109
ROCKY RIVER OH
44116-3901
US

IV. Provider business mailing address

2500 METROHEALTH DR
CLEVELAND OH
44109-1900
US

V. Phone/Fax

Practice location:
  • Phone: 440-331-5488
  • Fax:
Mailing address:
  • Phone: 330-881-2713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.005881RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: