Healthcare Provider Details

I. General information

NPI: 1255759627
Provider Name (Legal Business Name): CHISOM C. IWUEKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2014
Last Update Date: 09/02/2022
Certification Date: 09/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 TIMBERLINE TRL
NORTH CHARLESTON SC
29418-3067
US

IV. Provider business mailing address

980 JOHNSON FERRY RD STE 660
SANDY SPRINGS GA
30342-1608
US

V. Phone/Fax

Practice location:
  • Phone: 864-905-4747
  • Fax:
Mailing address:
  • Phone: 404-847-1592
  • Fax:

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 State
# 2
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number89076
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: