1417476409 NPI number — CHRISTELLA AJONG MBEBOH MD

Table of content: CHRISTELLA AJONG MBEBOH MD (NPI 1417476409)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417476409 NPI number — CHRISTELLA AJONG MBEBOH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MBEBOH
Provider First Name:
CHRISTELLA
Provider Middle Name:
AJONG
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:
NKIANGWOA
Provider Other First Name:
CHRISTELLA
Provider Other Middle Name:
AJONG
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:
1417476409
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
461 W HURON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PONTIAC
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48341-1601
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-857-7200
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11116 MEDICAL CAMPUS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAGERSTOWN
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21742-6710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-790-8000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/12/2017

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:  5315089004 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 4301113710 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: D89081 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X , with the licence number: D89081 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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