1548377559 NPI number — DR. PATIENCE OKPAKU ADESIDA MD

Table of content: DR. PATIENCE OKPAKU ADESIDA MD (NPI 1548377559)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548377559 NPI number — DR. PATIENCE OKPAKU ADESIDA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ADESIDA
Provider First Name:
PATIENCE
Provider Middle Name:
OKPAKU
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
OKPAKU
Provider Other First Name:
PATIENCE
Provider Other Middle Name:
OTUEDON
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1548377559
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/27/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2008 N MARKET ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHAMPAIGN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61822-1308
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-239-6667
Provider Business Mailing Address Fax Number:
217-239-6670

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2008 N MARKET ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHAMPAIGN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61822-1308
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-239-6667
Provider Business Practice Location Address Fax Number:
217-239-6670
Provider Enumeration Date:
08/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  036075310 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 173634 . This is a "PERSONAL CARE HMO" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036075310 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01027388 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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