=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265698922
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHIAZOM C OMERUAH D.O.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2008
-----------------------------------------------------
Last Update Date | 03/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1240 EAGLES LANDING PKWY STE 110
-----------------------------------------------------
City | STOCKBRIDGE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30281-5173
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-389-3855
-----------------------------------------------------
Fax | 770-474-8078
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1240 EAGLES LANDING PKWY STE 110
-----------------------------------------------------
City | STOCKBRIDGE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30281-5173
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-389-3855
-----------------------------------------------------
Fax | 770-474-8078
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | OS015547
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | DO.1225
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 75091
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------