Provider Demographics
NPI:1902098734
Name:GATEWAY MEDICAL CLINICS, LLC
Entity Type:Organization
Organization Name:GATEWAY MEDICAL CLINICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WAHEED
Authorized Official - Middle Name:
Authorized Official - Last Name:ADEWUMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:513-326-2040
Mailing Address - Street 1:11497 SPRINGFIELD PIKE STE 5
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:OH
Mailing Address - Zip Code:45246-3551
Mailing Address - Country:US
Mailing Address - Phone:513-326-2040
Mailing Address - Fax:
Practice Address - Street 1:11497 SPRINGFIELD PIKE STE 5
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:OH
Practice Address - Zip Code:45246-3551
Practice Address - Country:US
Practice Address - Phone:513-326-2040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-15
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-083640261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000371883OtherANTHEM
OHP00277464OtherMEDICARE RR
OH7101685OtherAETNA
OH2496375Medicaid
OH213311832006OtherMEDICAL MUTUAL
OH000000371883OtherANTHEM