Healthcare Provider Details

I. General information

NPI: 1194279539
Provider Name (Legal Business Name): KEJO MEDICAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2016
Last Update Date: 08/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E MILITARY RD
MARION AR
72364-1811
US

IV. Provider business mailing address

200 E MILITARY RD
MARION AR
72364-1811
US

V. Phone/Fax

Practice location:
  • Phone: 248-747-1735
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. CHUKWUEMEKA NDUBISI EZEUME
Title or Position: CO-OWNER
Credential: M.D
Phone: 662-321-7899