Healthcare Provider Details

I. General information

NPI: 1962866467
Provider Name (Legal Business Name): CHIDIEBUBE EGWIM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2016
Last Update Date: 01/06/2026
Certification Date: 01/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

252 S 4TH ST
LEBANON PA
17042-6111
US

IV. Provider business mailing address

601 MEMORY LN
YORK PA
17402-2231
US

V. Phone/Fax

Practice location:
  • Phone: 717-270-4876
  • Fax: 717-270-3875
Mailing address:
  • Phone: 717-851-1405
  • Fax: 717-851-6969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD488765
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number63160
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number63160
License Number StateTN
# 5
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberMD488765
License Number StatePA
# 6
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMD488765
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: