=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003994955
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROPHEKA MEDICAL SERVICE LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 551 W 103RD ST 1ST FLOOR EAST WING
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60628-2403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-779-9890
-----------------------------------------------------
Fax | 773-779-9830
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 745
-----------------------------------------------------
City | FOREST PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60130-0745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-214-5300
-----------------------------------------------------
Fax | 773-913-2314
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | SAMUEL TAIWO OLATUNBOSUN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 708-214-5300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------