Provider Demographics
NPI:1356530943
Name:CHARLES O. MBANEFO, MD
Entity type:Organization
Organization Name:CHARLES O. MBANEFO, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:O
Authorized Official - Last Name:MBANEFO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:216-368-5687
Mailing Address - Street 1:11201 SHAKER BLVD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44104-3869
Mailing Address - Country:US
Mailing Address - Phone:216-368-5687
Mailing Address - Fax:216-368-5623
Practice Address - Street 1:11201 SHAKER BLVD
Practice Address - Street 2:SUITE 130
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44104-3869
Practice Address - Country:US
Practice Address - Phone:216-368-5687
Practice Address - Fax:216-368-5623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-18
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-05-1577M174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
A82793Medicare UPIN