Healthcare Provider Details

I. General information

NPI: 1891680542
Provider Name (Legal Business Name): CHIDALU N. IBENEME MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2025
Last Update Date: 07/11/2026
Certification Date: 07/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HOSPITAL DR
COLUMBIA MO
65212-1000
US

IV. Provider business mailing address

3717 MONTEREY DR APT C
COLUMBIA MO
65203-3787
US

V. Phone/Fax

Practice location:
  • Phone: 419-204-9575
  • Fax:
Mailing address:
  • Phone: 419-204-9575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2024048683
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2026026615
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: