1952496770 NPI number — NKIRUKA J UDEJIOFOR MD

Table of content: NKIRUKA J UDEJIOFOR MD (NPI 1952496770)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952496770 NPI number — NKIRUKA J UDEJIOFOR MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
UDEJIOFOR
Provider First Name:
NKIRUKA
Provider Middle Name:
J
Provider Name Prefix Text:
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:
ONWUBIKO
Provider Other First Name:
NKIRUKA
Provider Other Middle Name:
J
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1952496770
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/03/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3495 PIEDMONT ROAD, NE
Provider Second Line Business Mailing Address:
NINE PIEDMONT CENTER
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-504-5678
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
750 TOWN PARK LANE
Provider Second Line Business Practice Location Address:
KAISER PERMANENLE TOWN PARK COMPREHENSIVE MEDICAL CENTE
Provider Business Practice Location Address City Name:
KENNESAW
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30144
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-514-5401
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/04/2006

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: 207Q00000X , with the licence number:  01061199A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 059340 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GA1145 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003104939B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003104939A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00924822 . This is a "RR MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".