Healthcare Provider Details

I. General information

NPI: 1316358518
Provider Name (Legal Business Name): JEREOHA CHIDERALUM NWOBODO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2014
Last Update Date: 04/12/2024
Certification Date: 04/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 OAKDALE AVE N
ROBBINSDALE MN
55422
US

IV. Provider business mailing address

3300 OAKDALE AVE N
ROBBINSDALE MN
55422-2926
US

V. Phone/Fax

Practice location:
  • Phone: 763-520-5200
  • Fax: 763-581-4771
Mailing address:
  • Phone: 763-520-5200
  • Fax: 763-581-4771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number63986
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number63986
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: