Healthcare Provider Details

I. General information

NPI: 1669384194
Provider Name (Legal Business Name): MATTHEW CHIDI EHIRIM PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 HIGHGROVE WAY
DALLAS GA
30157-7426
US

IV. Provider business mailing address

811 HIGHGROVE WAY
DALLAS GA
30157-7426
US

V. Phone/Fax

Practice location:
  • Phone: 678-847-1702
  • Fax:
Mailing address:
  • Phone: 678-847-1702
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: