Basic Information
| Provider Information | |||||||||
| NPI: | 1760485007 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AKINTILO | ||||||||
| FirstName: | OLATUNJI | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1701 E COURT ST | ||||||||
| Address2: | |||||||||
| City: | KANKAKEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 609012670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159359394 | ||||||||
| FaxNumber: | 8159351187 | ||||||||
| Practice Location | |||||||||
| Address1: | 1701 E COURT ST | ||||||||
| Address2: | |||||||||
| City: | KANKAKEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 609012670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159359394 | ||||||||
| FaxNumber: | 8159351187 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2005 | ||||||||
| LastUpdateDate: | 10/13/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 10/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 37594 | WI | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 37594 | WI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 036094325 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036094325 | 05 | IL | MEDICAID | 4632039 | 01 | IL | BC | OTHER | 32231400 | 05 | WI | MEDICAID |