Provider Demographics
NPI:1609168640
Name:IKENNA F. ONYEBUEKE, MD PA
Entity Type:Organization
Organization Name:IKENNA F. ONYEBUEKE, MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DARLA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:RRT
Authorized Official - Phone:864-582-6858
Mailing Address - Street 1:PO BOX 4276
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29305-4276
Mailing Address - Country:US
Mailing Address - Phone:864-582-6858
Mailing Address - Fax:864-585-0999
Practice Address - Street 1:2030 NORTH CHURCH PLACE
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-2799
Practice Address - Country:US
Practice Address - Phone:864-582-6858
Practice Address - Fax:864-585-0999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-10
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP5733Medicaid
SCGP5733Medicaid