Provider Demographics
NPI:1689614414
Name:NEPHROLOGY & INTENSIVE CARE ASSOC PLLC
Entity Type:Organization
Organization Name:NEPHROLOGY & INTENSIVE CARE ASSOC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OMOKAYODE
Authorized Official - Middle Name:ADEBISI
Authorized Official - Last Name:OSOBAMIRO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-228-7433
Mailing Address - Street 1:PO BOX 82057
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48308-2057
Mailing Address - Country:US
Mailing Address - Phone:248-969-3220
Mailing Address - Fax:248-274-5059
Practice Address - Street 1:16151 19 MILE RD
Practice Address - Street 2:SUITE 301
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-1158
Practice Address - Country:US
Practice Address - Phone:586-228-7433
Practice Address - Fax:586-412-3924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301059326207R00000X, 207RC0200X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI10 4841551Medicaid
MI1105018352OtherBCBSM