Provider Demographics
NPI:1427165109
Name:ILECHUKWU, IFEYINWA (MD)
Entity type:Individual
Prefix:
First Name:IFEYINWA
Middle Name:
Last Name:ILECHUKWU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10350 W 9 MILE RD
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-2913
Mailing Address - Country:US
Mailing Address - Phone:248-541-6630
Mailing Address - Fax:248-541-6631
Practice Address - Street 1:10350 W 9 MILE RD
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-2913
Practice Address - Country:US
Practice Address - Phone:248-541-6630
Practice Address - Fax:248-541-6631
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301072967208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
373880OtherAETNA
MI250823437OtherBLUE CROSS OF MI
MI4695533Medicaid
7900526OtherAETNA HMO
5594424OtherFIRST HEALTH NETWORK
000000013644OtherCAPE
MI4695533Medicaid
MI250823437OtherBLUE CROSS OF MI
MI0P14490Medicare PIN