Healthcare Provider Details

I. General information

NPI: 1154336634
Provider Name (Legal Business Name): BEDE IKENNA NNOLIM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 07/29/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

953 SOUTHERN BLVD
BRONX NY
10459-3428
US

IV. Provider business mailing address

953 SOUTHERN BLVD
BRONX NY
10459-3428
US

V. Phone/Fax

Practice location:
  • Phone: 718-589-4541
  • Fax:
Mailing address:
  • Phone:
  • Fax: 910-292-2091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number327537
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: