MEDICARE: IFEANYI EJIEGO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171W00000X	Contractor

General Provider Information

NPI Number	:	1588051189
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IFEANYI EJIEGO

Provider Business Mailing Address
First Line	:	9712 S ORANGE AVE
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32824-7211
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9712 S ORANGE AVE
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32824-7211
Country	:	US
Telephone Number	:	844-395-4100
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/21/2015
Last Update Date	:	04/21/2015

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Directions to “ IFEANYI EJIEGO ” Practice Location

Language	Start Address	Practice Location

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