Provider Demographics
NPI:1013163765
Name:FAGBEMI, OLUMIDE SAMSON (NP)
Entity Type:Individual
Prefix:MR
First Name:OLUMIDE
Middle Name:SAMSON
Last Name:FAGBEMI
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1118 LUCAS ST
Mailing Address - Street 2:
Mailing Address - City:CALUMET CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60409-2408
Mailing Address - Country:US
Mailing Address - Phone:708-785-2238
Mailing Address - Fax:
Practice Address - Street 1:1118 LUCAS ST
Practice Address - Street 2:
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409-2408
Practice Address - Country:US
Practice Address - Phone:708-785-2238
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-13
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.022296363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily