Healthcare Provider Details

I. General information

NPI: 1407540040
Provider Name (Legal Business Name): CHIDERA MGBUDEM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2023
Last Update Date: 02/20/2024
Certification Date: 02/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 ARNET ST STE 200
YPSILANTI MI
48198-5753
US

IV. Provider business mailing address

2120 GLENCOE HILLS DR APT 11
ANN ARBOR MI
48108-1085
US

V. Phone/Fax

Practice location:
  • Phone: 216-392-8538
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4351050734
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: