Provider Demographics
NPI:1225073109
Name:IROEGBU, NKEMAKOLAM (MD)
Entity Type:Individual
Prefix:MR
First Name:NKEMAKOLAM
Middle Name:
Last Name:IROEGBU
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:PO BOX 6309
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46660-6309
Mailing Address - Country:US
Mailing Address - Phone:574-335-8700
Mailing Address - Fax:574-335-0760
Practice Address - Street 1:1915 LAKE AVE
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-9366
Practice Address - Country:US
Practice Address - Phone:574-335-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036091295207R00000X
IN01042876207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01628310OtherBCBS PROVIDER #
IN201169800Medicaid
IN000000877923OtherBCBS
IL036091925Medicaid
IL036091925Medicaid
IN201169800Medicaid
ILF65380Medicare UPIN