Provider Demographics
NPI:1972733061
Name:OLUWABUSI, OLUMIDE OLUREMI (MD, MRCPSYCH)
Entity type:Individual
Prefix:DR
First Name:OLUMIDE
Middle Name:OLUREMI
Last Name:OLUWABUSI
Suffix:
Gender:M
Credentials:MD, MRCPSYCH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4641 ROOSEVELT BLVD ,SCATTERGOOD BUILDING, SUITE E 218
Mailing Address - Street 2:DREXEL UNIVERSITY COLLEGE OF MEDICINE FRIENDS HOSPITAL
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19124-2343
Mailing Address - Country:US
Mailing Address - Phone:215-762-7000
Mailing Address - Fax:
Practice Address - Street 1:4641 ROOSEVELT BOULEVARD, SCATTERGOOD BLDG, SUITE E 218
Practice Address - Street 2:DREXEL UNIVERSITY COLLEGE OF MEDICINE, FRIENDS HOSPITAL
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19124
Practice Address - Country:US
Practice Address - Phone:215-831-4041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-23
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT1904742084P0800X
PAMD4410592084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMD441059OtherPENNSYLVANIA STATE BOARD OF MEDICINE, M.D., PRACTICE LICENSE,
PAMT190474OtherPENNSYLVANIA, MEDICAL TRAINING LICENCE