Healthcare Provider Details

I. General information

NPI: 1144504408
Provider Name (Legal Business Name): NWABUNDO IFEYINWA ANUSIM M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2011
Last Update Date: 06/30/2021
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 TRINITY ST
AUSTIN TX
78712-1765
US

IV. Provider business mailing address

1601 TRINITY ST
AUSTIN TX
78712-1765
US

V. Phone/Fax

Practice location:
  • Phone: 574-335-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number125058994
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number4301114550
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number01073275A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: