MEDICARE: ABIODUN SANGOSENI MD

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	207R00000X	Internal Medicine Physician		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	196690	OTHER		BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1194710483
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ABIODUN SANGOSENI MD

Provider Business Mailing Address
First Line	:	PO BOX 66971
Second Line	:	DEPT LE
City	:	SAINT LOUIS
State	:	MO
Zip	:	63166-6971
Country	:	US
Telephone Number	:	800-968-6866
Fax Number	:

Provider Business Practice Location Address
First Line	:	17 GINGER CREEK MDWS
Second Line	:
City	:	GLEN CARBON
State	:	IL
Zip	:	62034-3508
Country	:	US
Telephone Number	:	800-968-6866
Fax Number	:

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

Provider Enumeration Date	:	09/13/2005
Last Update Date	:	08/07/2007

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