Basic Information
Provider Information | |||||||||
NPI: | 1669448221 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | UGWONALI | ||||||||
FirstName: | OBINWANNE | ||||||||
MiddleName: | FIDELIS C | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5505 PEACHTREE DUNWOODY RD NE | ||||||||
Address2: | SUITE 600 | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303421705 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4043550743 | ||||||||
FaxNumber: | 4044251071 | ||||||||
Practice Location | |||||||||
Address1: | 5505 PEACHTREE DUNWOODY RD NE | ||||||||
Address2: | SUITE 600 | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303421705 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4043550743 | ||||||||
FaxNumber: | 4044251071 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/24/2006 | ||||||||
LastUpdateDate: | 12/12/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0106X | 057508 | GA | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 207X00000X | 057508 | GA | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 478817 | 01 | MA | TUFTS HEALTH PLAN | OTHER | J29526 | 01 | MA | BCBS MA | OTHER | 2112272 | 05 | MA |   | MEDICAID |