Provider Demographics
NPI:1184612731
Name:CHIMA OHAEGBULAM, MD PC
Entity type:Organization
Organization Name:CHIMA OHAEGBULAM, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHIMA
Authorized Official - Middle Name:
Authorized Official - Last Name:OHAEGBULAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-754-6025
Mailing Address - Street 1:125 PARKER HILL AVE
Mailing Address - Street 2:CONVERSE 5
Mailing Address - City:ROXBURY CROSSING
Mailing Address - State:MA
Mailing Address - Zip Code:02120-2847
Mailing Address - Country:US
Mailing Address - Phone:617-754-6025
Mailing Address - Fax:617-754-6026
Practice Address - Street 1:125 PARKER HILL AVE
Practice Address - Street 2:CONVERSE 5
Practice Address - City:ROXBURY CROSSING
Practice Address - State:MA
Practice Address - Zip Code:02120-2847
Practice Address - Country:US
Practice Address - Phone:617-754-6025
Practice Address - Fax:617-754-6026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-07
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA160498207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAA43609OtherHPHC
MA494197OtherTUFTS
MA9737171Medicaid
MAM21694Medicare UPIN
MA9737171Medicaid