Provider Demographics
NPI:1508804162
Name:ECHERUO, ROSE NKEONYERE
Entity Type:Individual
Prefix:DR
First Name:ROSE
Middle Name:NKEONYERE
Last Name:ECHERUO
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:ROSE
Other - Middle Name:NKEONYERE
Other - Last Name:IKWUEKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1200 E GENESEE ST
Mailing Address - Street 2:STE 208
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1968
Mailing Address - Country:US
Mailing Address - Phone:315-425-9113
Mailing Address - Fax:
Practice Address - Street 1:1200 E GENESEE ST
Practice Address - Street 2:STE 208
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1968
Practice Address - Country:US
Practice Address - Phone:315-425-9113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY204071207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02201201Medicaid
NYG88827Medicare UPIN
NYCC9004Medicare ID - Type Unspecified