Basic Information
Provider Information
NPI: 1003006503
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: JEGEDE
FirstName: OLUGBEMIGA
MiddleName: EBENEZER
NamePrefix: DR.
NameSuffix:  
Credential: M.D
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 801 TUURI PL
Address2: APT. # 217
City: FLINT
State: MI
PostalCode: 485032481
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: ONE HURLEY PLAZA
Address2: HURLEY MEDICAL CENTER
City: FLINT
State: MI
PostalCode: 485035993
CountryCode: US
TelephoneNumber: 8102579000
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/31/2007
LastUpdateDate: 07/31/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207R00000X4301090347MIY Allopathic & Osteopathic PhysiciansInternal Medicine 

No ID Information.


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