Provider Demographics
NPI:1346588134
Name:OBASEKI INDIANA FAMILY HEALTH CLINIC, PROF. CORP.
Entity Type:Organization
Organization Name:OBASEKI INDIANA FAMILY HEALTH CLINIC, PROF. CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ART
Authorized Official - Middle Name:O
Authorized Official - Last Name:OBASEKI
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:812-491-8765
Mailing Address - Street 1:645 CANAL ST
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47713-2441
Mailing Address - Country:US
Mailing Address - Phone:812-491-8765
Mailing Address - Fax:812-491-8766
Practice Address - Street 1:645 CANAL ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47713-2441
Practice Address - Country:US
Practice Address - Phone:812-491-8765
Practice Address - Fax:812-491-8766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-29
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01039780A208100000X
IN71000903A364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily HealthGroup - Single Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000354966OtherANTHEM
IN200512070Medicaid
IN256580Medicare PIN