Basic Information
| Provider Information | |||||||||
| NPI: | 1114040904 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHINWEZE | ||||||||
| FirstName: | EBELECHUKWU | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8400 LOUISIANA ST | ||||||||
| Address2: | |||||||||
| City: | MERRILLVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464106385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197571928 | ||||||||
| FaxNumber: | 2195751950 | ||||||||
| Practice Location | |||||||||
| Address1: | 3901 MERCY DR | ||||||||
| Address2: | |||||||||
| City: | MCHENRY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600503151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153638800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2007 | ||||||||
| LastUpdateDate: | 06/10/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 01072762A | IN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 201164250 | 05 | IN | MEDICAID |