=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588866479
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EZINMA EZEALAH MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2007
-----------------------------------------------------
Last Update Date | 02/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2104A WOODRUFF RD
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29607-5941
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-336-2323
-----------------------------------------------------
Fax | 864-236-4222
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2104A WOODRUFF RD
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29607-5941
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-336-2323
-----------------------------------------------------
Fax | 864-236-4222
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207KA0200X
-----------------------------------------------------
Taxonomy Name | Allergy Physician
-----------------------------------------------------
License Number | MD37517
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RR0500X
-----------------------------------------------------
Taxonomy Name | Rheumatology Physician
-----------------------------------------------------
License Number | MD37517
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------