Provider Demographics
NPI:1932156171
Name:EKUNSANMI, BAMIDELE A (MD)
Entity Type:Individual
Prefix:DR
First Name:BAMIDELE
Middle Name:A
Last Name:EKUNSANMI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1609 CONSTITUTION BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-3047
Mailing Address - Country:US
Mailing Address - Phone:803-326-3000
Mailing Address - Fax:803-326-3003
Practice Address - Street 1:1609 CONSTITUTION BLVD
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-3047
Practice Address - Country:US
Practice Address - Phone:803-326-3000
Practice Address - Fax:803-326-3003
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19921207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2318Medicaid
SCG763100281Medicare ID - Type UnspecifiedMEDICARE
SCGP2318Medicaid