Provider Demographics
NPI:1285684548
Name:EMOVON, OSEMWEGIE EMMANUEL (MD)
Entity Type:Individual
Prefix:
First Name:OSEMWEGIE
Middle Name:EMMANUEL
Last Name:EMOVON
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 81113
Mailing Address - Street 2:ASHLEY RIVER STATION
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29416-1113
Mailing Address - Country:US
Mailing Address - Phone:843-573-0499
Mailing Address - Fax:843-388-6292
Practice Address - Street 1:2093 HENRY TECKLENBURG DR
Practice Address - Street 2:SUITE 205E
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5741
Practice Address - Country:US
Practice Address - Phone:843-573-0499
Practice Address - Fax:843-388-6292
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22793S207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT70241Medicaid
SCF755658070Medicare ID - Type Unspecified
SCT70241Medicaid