Healthcare Provider Details

I. General information

NPI: 1366626343
Provider Name (Legal Business Name): HILARY IKENNA UFEARO MBBS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2007
Last Update Date: 04/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 CENTRACARE CIRCLE, #1600 CENTRACARE CLINIC HEALTH PLAZA SPECIALTIES/ONCOLOGY
ST CLOUD MN
56303-5000
US

IV. Provider business mailing address

1900 CENTRACARE CIRCLE, #1600 CENTRACARE CLINIC HEALTH PLAZA SPECIALTIES/ONCOLOGY
ST CLOUD MN
56303-5000
US

V. Phone/Fax

Practice location:
  • Phone: 320-229-4907
  • Fax:
Mailing address:
  • Phone: 320-229-4907
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberD66182
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberMN-TEMP104791
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: