Healthcare Provider Details

I. General information

NPI: 1730708884
Provider Name (Legal Business Name): IRUOMA GENEVIEVE NWANGWU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2020
Last Update Date: 05/16/2020
Certification Date: 05/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 W POLK STREET
CHICAGO IL
60612-3714
US

IV. Provider business mailing address

1950 W POLK STREET 1950 W POLK STR.
CHICAGO IL
60612-3714
US

V. Phone/Fax

Practice location:
  • Phone: 312-864-6000
  • Fax:
Mailing address:
  • Phone: 312-864-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125.076532
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: