Basic Information
| Provider Information | |||||||||
| NPI: | 1518951672 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OSOBAMIRO | ||||||||
| FirstName: | OMOKAYODE | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 82057 | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483082057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862287433 | ||||||||
| FaxNumber: | 2486939204 | ||||||||
| Practice Location | |||||||||
| Address1: | 16151 19 MILE RD STE 302 | ||||||||
| Address2: | |||||||||
| City: | CLINTON TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480381159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862287433 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2005 | ||||||||
| LastUpdateDate: | 12/29/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 4301059326 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RC0200X | 4301059326 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 10 4841551 | 05 | MI | MEDICAID | 1105018352 | 01 | MI | BCBSM | OTHER |