Provider Demographics
NPI:1700075686
Name:EFEM IMOKE, M.D., P.A.
Entity Type:Organization
Organization Name:EFEM IMOKE, M.D., P.A.
Other - Org Name:UNIVERSAL SURGICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF ADMINISTRATIVE AFFAIRS
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:CWIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-247-4740
Mailing Address - Street 1:4713 LEEDS AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21227-1402
Mailing Address - Country:US
Mailing Address - Phone:410-247-4740
Mailing Address - Fax:410-247-2346
Practice Address - Street 1:4713 LEEDS AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21227-1402
Practice Address - Country:US
Practice Address - Phone:410-247-4740
Practice Address - Fax:410-247-2346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-17
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0025902174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD920541100Medicaid
MD920541100Medicaid