Provider Demographics
NPI:1114055027
Name:EBBA, CELSUS IEGBEOJAI (MD)
Entity Type:Individual
Prefix:
First Name:CELSUS
Middle Name:IEGBEOJAI
Last Name:EBBA
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 1:869 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DARBY
Mailing Address - State:PA
Mailing Address - Zip Code:19023-2105
Mailing Address - Country:US
Mailing Address - Phone:610-461-2440
Mailing Address - Fax:610-461-2475
Practice Address - Street 1:869 MAIN ST
Practice Address - Street 2:
Practice Address - City:DARBY
Practice Address - State:PA
Practice Address - Zip Code:19023-2105
Practice Address - Country:US
Practice Address - Phone:610-461-2440
Practice Address - Fax:610-461-2475
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-047028-L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0124246000OtherKEYSTONE EAST
PA737499OtherAETNA
PA93191OtherBLUC CROSS BLUE SHIELD
PA232975236Medicare UPIN
PA737499OtherAETNA