1700075686 NPI number — EFEM IMOKE, M.D., P.A.

Table of content: (NPI 1700075686)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700075686 NPI number — EFEM IMOKE, M.D., P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EFEM IMOKE, M.D., P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1700075686
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/28/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4713 LEEDS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21227-1402
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-247-4740
Provider Business Mailing Address Fax Number:
410-247-2346

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4713 LEEDS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21227-1402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-247-4740
Provider Business Practice Location Address Fax Number:
410-247-2346
Provider Enumeration Date:
10/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CWIK
Authorized Official First Name:
CAROL
Authorized Official Middle Name:
LYN
Authorized Official Title or Position:
DIRECTOR OF ADMINISTRATIVE AFFAIRS
Authorized Official Telephone Number:
410-247-4740

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  D0025902 , 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)

  • Identifier: 920541100 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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