Provider Demographics
NPI:1003836446
Name:UMORU, BENEDICTA (MD)
Entity Type:Individual
Prefix:DR
First Name:BENEDICTA
Middle Name:
Last Name:UMORU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2015
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:62208-0215
Mailing Address - Country:US
Mailing Address - Phone:618-355-9970
Mailing Address - Fax:618-355-9972
Practice Address - Street 1:5032 N ILLINOIS ST
Practice Address - Street 2:STE B
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208-3415
Practice Address - Country:US
Practice Address - Phone:618-416-9005
Practice Address - Fax:618-641-9452
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036100162207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036100162Medicaid
P00248272OtherRR MEDICARE
08232145OtherBCBS IL
K14023Medicare PIN
08232145OtherBCBS IL
IL036100162Medicaid