Basic Information
| Provider Information | |||||||||
| NPI: | 1689614414 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEPHROLOGY & INTENSIVE CARE ASSOC PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 82057 | ||||||||
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| City: | ROCHESTER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483082057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489693220 | ||||||||
| FaxNumber: | 2482745059 | ||||||||
| Practice Location | |||||||||
| Address1: | 16151 19 MILE RD | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | CLINTON TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480381158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862287433 | ||||||||
| FaxNumber: | 5864123924 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 12/29/2020 | ||||||||
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| AuthorizedOfficialLastName: | OSOBAMIRO | ||||||||
| AuthorizedOfficialFirstName: | OMOKAYODE | ||||||||
| AuthorizedOfficialMiddleName: | ADEBISI | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5862287433 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 12/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301059326 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RN0300X | 4301059326 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RC0200X | 4301059326 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | 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 |