Healthcare Provider Details

I. General information

NPI: 1881950582
Provider Name (Legal Business Name): EGHOSA AIMUAMWOSA OLOMU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2012
Last Update Date: 05/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 E NORTH AVE
PITTSBURGH PA
15212-4756
US

IV. Provider business mailing address

320 E NORTH AVE
PITTSBURGH PA
15212-4756
US

V. Phone/Fax

Practice location:
  • Phone: 412-359-3131
  • Fax:
Mailing address:
  • Phone: 412-359-3131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMT204849
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: