Provider Demographics
NPI:1154624914
Name:NWACHUKWU MEDICAL ASSOCIATES, PA
Entity type:Organization
Organization Name:NWACHUKWU MEDICAL ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IKENNA
Authorized Official - Middle Name:
Authorized Official - Last Name:NWACHUKWU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-367-0918
Mailing Address - Street 1:1411 MADISON PARK DR
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-6185
Mailing Address - Country:US
Mailing Address - Phone:410-553-6360
Mailing Address - Fax:410-553-6661
Practice Address - Street 1:1411 MADISON PARK DR
Practice Address - Street 2:SUITE 1B
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-6185
Practice Address - Country:US
Practice Address - Phone:410-553-6360
Practice Address - Fax:410-553-6661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-15
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0066985207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty