MEDICARE: DR. OLUSEGUN M ADEONIGBAGBE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RG0100X	Gastroenterology Physician	201260	NY

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00010034	OTHER		RAILROAD MEDICARE
11	03590	OTHER	NY	GHI MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2588825	OTHER		AETNA
3	QN0067201	OTHER		AMERICHOICE
4	3V1542	OTHER		BLUE CROSS BLUE SHIELD
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	3C2885	OTHER		HEALTHNET
7	111948722AD03	OTHER		CAREPLUS
8	2506098	OTHER	NY	GHI
9	000333540101	OTHER		HEALTHPLUS
10	P1300262	OTHER		OXFORD
12	201260	OTHER		HIP
13	201260-A16	OTHER		HEALTH FIRST

General Provider Information

NPI Number	:	1073570081
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. OLUSEGUN M ADEONIGBAGBE M.D.

Provider Business Mailing Address
First Line	:	1 NORFOLK DRIVE E
Second Line	:
City	:	ELMONT
State	:	NY
Zip	:	11003
Country	:	US
Telephone Number	:	718-217-7744
Fax Number	:	718-217-7233

Provider Business Practice Location Address
First Line	:	19203 JAMAICA AVE
Second Line	:
City	:	HOLLIS
State	:	NY
Zip	:	11423-2529
Country	:	US
Telephone Number	:	718-217-7744
Fax Number	:	718-217-7233

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/26/2006
Last Update Date	:	08/04/2008

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19203 JAMAICA AVE
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