Provider Demographics
NPI:1124845037
Name:YOUR DIRECT MD
Entity type:Organization
Organization Name:YOUR DIRECT MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NONSO
Authorized Official - Middle Name:
Authorized Official - Last Name:EZEMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-941-3516
Mailing Address - Street 1:658 W MARKET ST STE 106
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45801-5602
Mailing Address - Country:US
Mailing Address - Phone:567-970-3565
Mailing Address - Fax:
Practice Address - Street 1:658 W MARKET ST STE 106
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45801-5602
Practice Address - Country:US
Practice Address - Phone:567-970-3565
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty