Provider Demographics
NPI:1942244280
Name:EZENWA, BASIL (MD)
Entity Type:Individual
Prefix:
First Name:BASIL
Middle Name:
Last Name:EZENWA
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 532724
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30353-2724
Mailing Address - Country:US
Mailing Address - Phone:904-805-1300
Mailing Address - Fax:904-805-1302
Practice Address - Street 1:616 19TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-1528
Practice Address - Country:US
Practice Address - Phone:904-805-1300
Practice Address - Fax:904-805-1302
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA37797207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009922855Medicaid
GA000580082DMedicaid
GA616430OtherBLUE CROSS
GA616430OtherBLUE CROSS
GA93BBHZSMedicare PIN
GA000580082DMedicaid