Provider Demographics
NPI:1609921212
Name:ADEKANMBI, ADEBOLA K (MD)
Entity type:Individual
Prefix:DR
First Name:ADEBOLA
Middle Name:K
Last Name:ADEKANMBI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:271 NE EXECUTIVE PARK DRIVE
Mailing Address - Street 2:PROVIDENCE MEDICAL CLINIC, IN DBA CABARRUS MERCY CLINIC
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025
Mailing Address - Country:US
Mailing Address - Phone:704-707-4601
Mailing Address - Fax:
Practice Address - Street 1:271 EXECUTIVE PARK DR
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-1895
Practice Address - Country:US
Practice Address - Phone:704-721-4232
Practice Address - Fax:704-721-4232
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9900744207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H01190Medicare UPIN