Provider Demographics
NPI:1609048495
Name:PATIENCE O. ADESIDA M.D. LTD.
Entity Type:Organization
Organization Name:PATIENCE O. ADESIDA M.D. LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/PRESIDENT.
Authorized Official - Prefix:DR
Authorized Official - First Name:PATIENCE
Authorized Official - Middle Name:OKPAKU
Authorized Official - Last Name:ADESIDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-239-6667
Mailing Address - Street 1:2008 N MARKET ST
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-1308
Mailing Address - Country:US
Mailing Address - Phone:217-239-6667
Mailing Address - Fax:217-239-6670
Practice Address - Street 1:2008 N MARKET ST
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-1308
Practice Address - Country:US
Practice Address - Phone:217-239-6667
Practice Address - Fax:217-239-6670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-01
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036075310261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036075310Medicaid