Provider Demographics
NPI:1013185693
Name:NGUMI, PAUL G (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:G
Last Name:NGUMI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15620 WOOD ST
Mailing Address - Street 2:SOUTHWEST BUILDING
Mailing Address - City:HARVEY
Mailing Address - State:IL
Mailing Address - Zip Code:60426-4171
Mailing Address - Country:US
Mailing Address - Phone:708-333-3030
Mailing Address - Fax:708-333-6060
Practice Address - Street 1:15620 WOOD ST
Practice Address - Street 2:SOUTHWEST BUILDING
Practice Address - City:HARVEY
Practice Address - State:IL
Practice Address - Zip Code:60426-4171
Practice Address - Country:US
Practice Address - Phone:708-333-3030
Practice Address - Fax:708-333-6060
Is Sole Proprietor?:No
Enumeration Date:2008-02-15
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036053331174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036053331Medicaid
ILD14780Medicare UPIN