MEDICARE: MR. OLAIDE BABATOPE OLUSINA PHYSICAL THERAPIST

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	225100000X	Physical Therapist	2305005589	VA

General Provider Information

NPI Number	:	1861604837
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. OLAIDE BABATOPE OLUSINA PHYSICAL THERAPIST

Provider Business Mailing Address
First Line	:	PO BOX 3292
Second Line	:
City	:	GLEN ALLEN
State	:	VA
Zip	:	23058-3292
Country	:	US
Telephone Number	:	804-928-8771
Fax Number	:	804-449-1939

Provider Business Practice Location Address
First Line	:	15411 BEAVER DEN LN
Second Line	:
City	:	BEAVERDAM
State	:	VA
Zip	:	23015-2000
Country	:	US
Telephone Number	:	804-928-8771
Fax Number	:	804-449-1939

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

Provider Enumeration Date	:	05/04/2007
Last Update Date	:	07/09/2007

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