Healthcare Provider Details

I. General information

NPI: 1326175936
Provider Name (Legal Business Name): PAUL L EZEUKWU MSPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: PAUL L BELLO

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 SOUTHAMPTON RD
PHILADELPHIA PA
19154-1205
US

IV. Provider business mailing address

2701 SOUTHAMPTON RD
PHILADELPHIA PA
19154-1205
US

V. Phone/Fax

Practice location:
  • Phone: 215-965-0326
  • Fax: 215-965-0377
Mailing address:
  • Phone: 215-965-0326
  • Fax: 215-965-0377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberPT018485
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: