Provider Demographics
NPI:1871706143
Name:OBASEKI INDIANA FAMILY HEALTH CLINIC, PROF. CORP.
Entity type:Organization
Organization Name:OBASEKI INDIANA FAMILY HEALTH CLINIC, PROF. CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:OBASEKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-254-2311
Mailing Address - Street 1:1110 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47501-3031
Mailing Address - Country:US
Mailing Address - Phone:812-254-2311
Mailing Address - Fax:
Practice Address - Street 1:1110 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IN
Practice Address - Zip Code:47501-3031
Practice Address - Country:US
Practice Address - Phone:812-254-2311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01027289207QH0002X
IN01039780A2081H0002X
IN71000903A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative MedicineGroup - Multi-Specialty
Not Answered2081H0002XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationHospice and Palliative MedicineGroup - Multi-Specialty
Not Answered363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN2500512070Medicaid