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General NPI Number Information
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NPI Number | 1164652822
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Entity Type | Organization
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Legal Business Name | MID OHIO INFECTIOUS DISEASES CLINIC LLC
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Dates
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Enumeration Date | 07/16/2009
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Last Update Date | 07/16/2009
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Provider Practice Location Address
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Address Line | 630 LEXINGTON AVE
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City | MANSFIELD
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State | OH
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Zip | 44907-1500
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Country | US
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Telephone | 412-708-1608
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 5096
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City | MANSFIELD
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State | OH
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Zip | 44901-5096
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | DR. UCHENNA A EZIKE
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Credential | MD
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Telephone | 412-708-1608
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | 35093594
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License Number State | OH
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