Healthcare Provider Details

I. General information

NPI: 1114759396
Provider Name (Legal Business Name): BEAUTY UYAI NKEREUWEM ETUKUDOH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2024
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 BALLARD RD
PARK RIDGE IL
60068-1005
US

IV. Provider business mailing address

2600 GOLF RD APT 600
GLENVIEW IL
60025-4748
US

V. Phone/Fax

Practice location:
  • Phone: 847-318-9340
  • Fax: 847-318-2966
Mailing address:
  • Phone: 224-598-9239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number125.083606
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125.083606
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: