1427285311 NPI number — DR. IMUDIA DEKONTE EHANIRE MD

Table of content: DR. IMUDIA DEKONTE EHANIRE MD (NPI 1427285311)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427285311 NPI number — DR. IMUDIA DEKONTE EHANIRE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EHANIRE
Provider First Name:
IMUDIA
Provider Middle Name:
DEKONTE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1427285311
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/08/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1215
Provider Second Line Business Mailing Address:
ATTN CLINIC BILLING OFFICE
Provider Business Mailing Address City Name:
LIBERAL
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67905-1215
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
620-629-6638
Provider Business Mailing Address Fax Number:
620-629-6684

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
305 W 15TH ST
Provider Second Line Business Practice Location Address:
STE 204
Provider Business Practice Location Address City Name:
LIBERAL
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67901-2455
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-624-4946
Provider Business Practice Location Address Fax Number:
620-624-2260
Provider Enumeration Date:
06/17/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  0439349 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200655770A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 201142810A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




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