Basic Information
| Provider Information | |||||||||
| NPI: | 1417988445 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AJAELO | ||||||||
| FirstName: | IKEMEFUNA | ||||||||
| MiddleName: | CHUKWUEMEKA | ||||||||
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| OtherLastName: | AJAELO | ||||||||
| OtherFirstName: | IKEM | ||||||||
| OtherMiddleName: | CHUKWUEMEKA | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1450 TREAT BLVD STE 160 | ||||||||
| Address2: | |||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945972168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9252969000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 750 E 34TH ST | ||||||||
| Address2: | |||||||||
| City: | HIBBING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557462341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182624881 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 08/06/2019 | ||||||||
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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 | 207P00000X | 47833 | MN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 851458500 | 05 | MN | MEDICAID |