MEDICARE: MAGNUS E EDOSOMWAN 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	208M00000X	Hospitalist Physician	036-085865	IL
2	207R00000X	Internal Medicine Physician	036085865	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1215959176
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAGNUS E EDOSOMWAN MD

Provider Business Mailing Address
First Line	:	PO BOX 967
Second Line	:
City	:	TINLEY PARK
State	:	IL
Zip	:	60477-0967
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1738 W 99TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60643-2116
Country	:	US
Telephone Number	:	773-233-2408
Fax Number	:

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

Provider Enumeration Date	:	07/23/2006
Last Update Date	:	12/09/2020

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Directions to “ MAGNUS E EDOSOMWAN MD” Practice Location

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