Basic Information
| Provider Information | |||||||||
| NPI: | 1174523690 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MBAEZUE | ||||||||
| FirstName: | NKECHI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 WESTVIEW DR SW | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303101458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047561400 | ||||||||
| FaxNumber: | 4047565274 | ||||||||
| Practice Location | |||||||||
| Address1: | 80 JESSIE HILL JR DR | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046161000 | ||||||||
| FaxNumber: | 4046165933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2005 | ||||||||
| LastUpdateDate: | 01/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 044014 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00777158D | 05 | GA | MEDICAID |