=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043298615
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROTIMI A ILUYOMADE MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2006
-----------------------------------------------------
Last Update Date | 04/19/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6922 LITTLE RIVER TPKE STE D
-----------------------------------------------------
City | ANNANDALE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22003-3285
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-705-9306
-----------------------------------------------------
Fax | 703-890-3114
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 900 HOSPITAL DR
-----------------------------------------------------
City | MADISONVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42431-1644
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-825-5100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 0101221294
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | D0042228
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------