Provider Demographics
NPI:1154393171
Name:IGBINIGIE, THEODORE OSARUMWENSE (MD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:OSARUMWENSE
Last Name:IGBINIGIE
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 1:2085 FRONTIS PLAZA BLVD
Mailing Address - Street 2:ATTN: FORSYTH MEDICAL GROUP
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-5614
Mailing Address - Country:US
Mailing Address - Phone:336-277-1480
Mailing Address - Fax:
Practice Address - Street 1:3333 SILAS CREEK PKWY
Practice Address - Street 2:ATTN: IPOF
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3013
Practice Address - Country:US
Practice Address - Phone:336-718-7080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9500940207R00000X
NC200100894208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
BI7389782OtherFEDERAL DEA
H54714Medicare UPIN
NCNCA501AMedicare PIN