Provider Demographics
NPI:1356328504
Name:EGIEBOR, EGHE (MD)
Entity Type:Individual
Prefix:DR
First Name:EGHE
Middle Name:
Last Name:EGIEBOR
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 68052
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-0052
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1418 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:MOUNT CARMEL
Practice Address - State:IL
Practice Address - Zip Code:62863-2638
Practice Address - Country:US
Practice Address - Phone:618-263-6302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036112265207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000225575OtherBLUE SHIELD
IN000000240785OtherBLUE SHIELD
IN200244860Medicaid
IL3932056OtherBLUE SHIELD
IN000000207079OtherBLUE SHIELD
IN200244860Medicaid
IN$$$$$$$$$OtherBLUE SHIELD
IL3932056OtherBLUE SHIELD
IN131180AAMedicare PIN
IN862280AAAMedicare PIN
IN000000240785OtherBLUE SHIELD
IN142190PPMedicare PIN