Healthcare Provider Details

I. General information

NPI: 1669644589
Provider Name (Legal Business Name): BAMIDELE A AJIBOLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2008
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 PAMPLICO HWY
FLORENCE SC
29505-6047
US

IV. Provider business mailing address

PO BOX 603898
CHARLOTTE NC
28260-3898
US

V. Phone/Fax

Practice location:
  • Phone: 843-674-2500
  • Fax:
Mailing address:
  • Phone: 843-792-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number244096
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number81916
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number064745
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number064745
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number58481
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: