Individual
MARJORIE MABONG NWOSU
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
3505 BROADWAY, MOUNT VERNON, IL 62864
(618) 242-3495
(618) 241-8775
Mailing address
2500 W REYNOLDS ST, PONTIAC, IL 61764-9774
(815) 844-6551
(815) 842-1793
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
4301068282
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1932164951
—
MI
01
—
35-0-41-0927-2
BCBS PIN
MI
01
—
833230
MEDICARE GROUP #
—
01
—
CA2182
RR GROUP #
—
01
—
P00792826
RR INDIVIDUAL #
—
Enumeration date
04/20/2006
Last updated
05/23/2012
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