Healthcare Provider Details

I. General information

NPI: 1386803989
Provider Name (Legal Business Name): EMMANUEL NEBECHUKWU EKULIDE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2008
Last Update Date: 06/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 PROGRESS STREET SUBURBAN TREATMENT ASSOCIATES
UNION NJ
07083
US

IV. Provider business mailing address

626 VARSITY ROAD
SOUTH ORANGE NJ
07079-2652
US

V. Phone/Fax

Practice location:
  • Phone: 908-687-7188
  • Fax: 908-687-0294
Mailing address:
  • Phone: 973-762-6311
  • Fax: 973-327-4601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number25MA03447200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: