Provider Demographics
NPI:1932164951
Name:NWOSU, MARJORIE MABONG (MD)
Entity Type:Individual
Prefix:
First Name:MARJORIE
Middle Name:MABONG
Last Name:NWOSU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 W REYNOLDS ST
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:IL
Mailing Address - Zip Code:61764-9774
Mailing Address - Country:US
Mailing Address - Phone:815-844-6551
Mailing Address - Fax:815-842-1793
Practice Address - Street 1:3505 BROADWAY
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864
Practice Address - Country:US
Practice Address - Phone:618-242-3495
Practice Address - Fax:618-241-8775
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301068282208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00792826OtherRR INDIVIDUAL #
MI1932164951Medicaid
833230OtherMEDICARE GROUP #
MI35-0-41-0927-2OtherBCBS PIN
CA2182OtherRR GROUP #
G99953Medicare UPIN
MIM53750045Medicare PIN
833230OtherMEDICARE GROUP #