Samson Ajibola Omowumi

Primary specialty

Psychiatric/Mental Health Nurse PractitionerTaxonomy code 363LP0808X

License

209.030167 Issued in IL

Practice address

5401 N Knoxville Ave
Peoria, IL 61614-5098

Phone

(614) 816-7589

NPI assigned

Aug 2, 2024

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in IL

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Nurse Practitioner

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Signify Health Medical Associates, PLLC

  • General Practice Physician
  • Dallas, TX
  • NPI 1750845863

  IL

  Medicare reassignment NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1722556800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1722556800000",
    "number": "1457181877",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "10830 N SAWMILL LN",
            "city": "DUNLAP",
            "state": "IL",
            "postal_code": "615257514",
            "telephone_number": "614-816-7589"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5401 N KNOXVILLE AVE",
            "city": "PEORIA",
            "state": "IL",
            "postal_code": "616145098",
            "telephone_number": "614-816-7589"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "OMOWUMI",
        "first_name": "SAMSON",
        "middle_name": "AJIBOLA",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2024-08-02",
        "last_updated": "2024-08-02",
        "certification_date": "2024-08-02",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LP0808X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": "IL",
            "license": "209.030167",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Bret Olson, MD
• Jessica Olson
• Richard Alan Olson, D.C.
• Tamara L. Olt, M.D.
• Erin Omalley
• Oncology Hematology Associates of Central Il, PC (Illinois CancerCare, PC)
• Oncology-Hematology Associates of Central Illinois P C (Illinois Cancer Care PC)
• Oncology-Hematology Associates of Central Illinois P C
• Oneopto Il 2 PLLC (All About Eyes)
• Angie Christine Onion

• Psychiatric/Mental Health Nurse Practitioner in Peoria, IL
• Providers in Peoria, IL by specialty
• Psychiatric/Mental Health Nurse Practitioner in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 2, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.