Provider Demographics
NPI:1699746990
Name:EJIANREH, FIDELIS O (DO)
Entity type:Individual
Prefix:
First Name:FIDELIS
Middle Name:O
Last Name:EJIANREH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 CRICKLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16803-1899
Mailing Address - Country:US
Mailing Address - Phone:814-234-2226
Mailing Address - Fax:814-234-2258
Practice Address - Street 1:2032 E PLEASANT VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16602
Practice Address - Country:US
Practice Address - Phone:814-684-3101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABE8240652207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019586950001Medicaid
PA066862Medicare ID - Type Unspecified
PAH77850Medicare UPIN