MEDICARE: PUREWELL MEDICAL CLINIC LLC

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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1891640637
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PUREWELL MEDICAL CLINIC LLC

Provider Business Mailing Address
First Line	:	1957 OUTER PARK DR
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62704-3323
Country	:	US
Telephone Number	:	773-526-8121
Fax Number	:

Provider Business Practice Location Address
First Line	:	1912 W 103RD ST STE A
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60643-2625
Country	:	US
Telephone Number	:	773-526-8121
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KOLAWOLE KAYODE OYEWOLE
Credential	:	MD
Telephone Number	:	773-526-8121

Provider Enumeration Date	:	02/26/2026
Last Update Date	:	02/26/2026

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