Provider Demographics
NPI:1417234048
Name:EGBE, CHARLES
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:EGBE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 TAYLOR AVENUE
Mailing Address - Street 2:SUITE 304
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21286
Mailing Address - Country:US
Mailing Address - Phone:410-616-9679
Mailing Address - Fax:410-616-9687
Practice Address - Street 1:1055 TAYLOR AVENUE
Practice Address - Street 2:SUITE 304
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21286
Practice Address - Country:US
Practice Address - Phone:410-616-9679
Practice Address - Fax:410-616-9687
Is Sole Proprietor?:No
Enumeration Date:2011-11-10
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR3088376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator