Healthcare Provider Details

I. General information

NPI: 1710506712
Provider Name (Legal Business Name): OGAGA NYEROVWO URHIE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2020
Last Update Date: 05/25/2023
Certification Date: 05/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 W POLK ST
CHICAGO IL
60612-3723
US

IV. Provider business mailing address

22216 101ST AVE
QUEENS VILLAGE NY
11429-1650
US

V. Phone/Fax

Practice location:
  • Phone: 312-864-7311
  • Fax: 312-864-9725
Mailing address:
  • Phone: 304-521-7661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125.081920
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: