Healthcare Provider Details

I. General information

NPI: 1902802515
Provider Name (Legal Business Name): PRINCEWILL U EHIRIM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 04/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 MEDICAL CENTER BLVD SUITE 200
LAWRENCEVILLE GA
30045-8708
US

IV. Provider business mailing address

500 MEDICAL CENTER BLVD SUITE 200
LAWRENCEVILLE GA
30045-8708
US

V. Phone/Fax

Practice location:
  • Phone: 678-916-7053
  • Fax: 678-826-0867
Mailing address:
  • Phone: 678-916-7053
  • Fax: 678-826-0867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number048508
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: