1801826961 NPI number — EMMANUEL ILOH MD

Table of content: EMMANUEL ILOH MD (NPI 1801826961)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801826961 NPI number — EMMANUEL ILOH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ILOH
Provider First Name:
EMMANUEL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1801826961
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/17/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3950 NEW COVINGTON PIKE STE 130
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38128-2595
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-388-0404
Provider Business Mailing Address Fax Number:
901-388-0484

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3950 NEW COVINGTON PIKE STE 130
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38128-2595
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-388-0404
Provider Business Practice Location Address Fax Number:
901-388-0484
Provider Enumeration Date:
07/04/2006

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: 207P00000X , with the licence number:  38934 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 038934 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4114553 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3898246 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3898249 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4114557 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".