Basic Information
| Provider Information | |||||||||
| NPI: | 1225073109 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IROEGBU | ||||||||
| FirstName: | NKEMAKOLAM | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6309 | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466606309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5743358700 | ||||||||
| FaxNumber: | 5743350760 | ||||||||
| Practice Location | |||||||||
| Address1: | 1915 LAKE AVE | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465639366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5743355000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2006 | ||||||||
| LastUpdateDate: | 05/08/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036091295 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 01042876 | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01628310 | 01 | IL | BCBS PROVIDER # | OTHER | B14175065 | 01 | IL | DEA # | OTHER | 201169800 | 05 | IN | MEDICAID | 000000877923 | 01 | IN | BCBS | OTHER | 036091925 | 05 | IL | MEDICAID |