Provider Demographics
NPI:1154336634
Name:NNOLIM, BEDE IKENNA (MD)
Entity type:Individual
Prefix:DR
First Name:BEDE
Middle Name:IKENNA
Last Name:NNOLIM
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 1:953 SOUTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10459-3428
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:910-292-2091
Practice Address - Street 1:953 SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10459-3428
Practice Address - Country:US
Practice Address - Phone:718-589-4541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY327537207RE0101X
OH35088264207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4803031Medicaid
MIM40150110Medicare ID - Type UnspecifiedFEE LOCAL 99
MI4803031Medicaid
MIF37432147Medicare ID - Type UnspecifiedFEE LOCAL 01