Basic Information
| Provider Information | |||||||||
| NPI: | 1972701217 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AJAYI | ||||||||
| FirstName: | OLUYEMI | ||||||||
| MiddleName: | ADEBOWALE | ||||||||
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| Credential: | MBBS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 SIXTH AVE N | ||||||||
| Address2: | CENTRACARE CLINIC | ||||||||
| City: | ST CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563032735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202512700 | ||||||||
| FaxNumber: | 9373523580 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 SIXTH AVE N | ||||||||
| Address2: | CENTRACARE CLINIC | ||||||||
| City: | ST CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563032735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202512700 | ||||||||
| FaxNumber: | 9373523580 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2007 | ||||||||
| LastUpdateDate: | 10/30/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 35090323 | OH | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 35090323 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 55013 | MN | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | P00446750 | 01 | OH | RAILROAD MEDICARE | OTHER | 2793080 | 05 | OH | MEDICAID | 000000530884 | 01 | OH | ANTHEM | OTHER | 1972701217 | 05 | MN | MEDICAID | 9164059 | 01 | OH | AETNA | OTHER |