Healthcare Provider Details

I. General information

NPI: 1639356488
Provider Name (Legal Business Name): UKPENAHIUSI S IGHODARO P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2008
Last Update Date: 10/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

231 W MAIN ST STE 101
CARPENTERSVILLE IL
60110-1772
US

IV. Provider business mailing address

2040 OGDEN AVE 313
AURORA IL
60504-7205
US

V. Phone/Fax

Practice location:
  • Phone: 847-428-1515
  • Fax: 847-428-0024
Mailing address:
  • Phone: 630-692-5208
  • Fax: 630-499-2399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number070.009441
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: