1275714750 NPI number — MR. HENRY CHUKWUDI EBEM PT

Table of content: (NPI 1558077677)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275714750 NPI number — MR. HENRY CHUKWUDI EBEM PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EBEM
Provider First Name:
HENRY
Provider Middle Name:
CHUKWUDI
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1275714750
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/24/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2151 SETTLERS PARK LOOP
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROUND ROCK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78665-4669
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-552-7799
Provider Business Mailing Address Fax Number:
512-472-2021

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3218 E MARTIN LUTHER KING JR BLVD STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78721-1054
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-472-2020
Provider Business Practice Location Address Fax Number:
512-472-2021
Provider Enumeration Date:
11/26/2007

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: 225100000X , with the licence number:  1166630 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 193315201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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