Provider Demographics
NPI:1043541253
Name:CHUKWUMA EBO,M.D.,PA
Entity Type:Organization
Organization Name:CHUKWUMA EBO,M.D.,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHUWUMA
Authorized Official - Middle Name:
Authorized Official - Last Name:EBO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-391-6996
Mailing Address - Street 1:1124 MACE AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21221-3315
Mailing Address - Country:US
Mailing Address - Phone:410-391-6996
Mailing Address - Fax:410-687-6877
Practice Address - Street 1:1124 MACE AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21221-3315
Practice Address - Country:US
Practice Address - Phone:410-391-6996
Practice Address - Fax:410-687-6877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-28
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0061907207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD407505600Medicaid
MD407505600Medicaid