Healthcare Provider Details

I. General information

NPI: 1043298615
Provider Name (Legal Business Name): ROTIMI A ILUYOMADE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 04/19/2023
Certification Date: 04/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6922 LITTLE RIVER TPKE STE D
ANNANDALE VA
22003-3285
US

IV. Provider business mailing address

900 HOSPITAL DR
MADISONVILLE KY
42431-1644
US

V. Phone/Fax

Practice location:
  • Phone: 703-705-9306
  • Fax: 703-890-3114
Mailing address:
  • Phone: 270-825-5100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0101221294
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberD0042228
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: