Provider Demographics
NPI:1659768356
Name:MOBILE MEDICAL PROVIDER INC
Entity Type:Organization
Organization Name:MOBILE MEDICAL PROVIDER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ADESHOLA
Authorized Official - Middle Name:ABDULWAHID
Authorized Official - Last Name:AFOLABI
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE PRACTITIONER
Authorized Official - Phone:317-588-1039
Mailing Address - Street 1:12045 BODLEY PLACE
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-3714
Mailing Address - Country:US
Mailing Address - Phone:317-588-1039
Mailing Address - Fax:317-436-7002
Practice Address - Street 1:12045 BODLEY PLACE
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-3714
Practice Address - Country:US
Practice Address - Phone:317-588-1039
Practice Address - Fax:317-436-7002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-20
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207QH0002X, 207RH0002X, 2084H0002X, 363L00000X, 363LP0808X
IN28204676A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative MedicineGroup - Multi-Specialty
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative MedicineGroup - Multi-Specialty
No2084H0002XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyHospice and Palliative MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201176490Medicaid
IN000000826011OtherANTHEM
IN12544963OtherCAQH
IN945350028Medicare PIN