=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568965390
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | UCHE IKE MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2018
-----------------------------------------------------
Last Update Date | 08/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 930 MAR WALT DR UNIT C
-----------------------------------------------------
City | FORT WALTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32547
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-226-6801
-----------------------------------------------------
Fax | 877-413-5104
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3112 W WARREN BLVD APT 2E
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60612-1965
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-366-3970
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | ME155245
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------