Provider Demographics
NPI:1760075667
Name:ADELINE MEMORIAL MEDICAL GROUP PLLC
Entity Type:Organization
Organization Name:ADELINE MEMORIAL MEDICAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:FUNMILOLA
Authorized Official - Middle Name:O
Authorized Official - Last Name:ODUTAYO
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:832-344-3650
Mailing Address - Street 1:3200 AVENUE I
Mailing Address - Street 2:
Mailing Address - City:ROSENBERG
Mailing Address - State:TX
Mailing Address - Zip Code:77471-3630
Mailing Address - Country:US
Mailing Address - Phone:832-344-3650
Mailing Address - Fax:
Practice Address - Street 1:3200 AVENUE I
Practice Address - Street 2:
Practice Address - City:ROSENBERG
Practice Address - State:TX
Practice Address - Zip Code:77471-3630
Practice Address - Country:US
Practice Address - Phone:832-344-3650
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-11
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty