Basic Information
Provider Information | |||||||||
NPI: | 1902224199 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NCHEKWUBE | ||||||||
FirstName: | CHISALU | ||||||||
MiddleName: | T | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4140 SOUTHWEST HWY | ||||||||
Address2: |   | ||||||||
City: | HOMETOWN | ||||||||
State: | IL | ||||||||
PostalCode: | 604561135 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7084225700 | ||||||||
FaxNumber: | 7084229535 | ||||||||
Practice Location | |||||||||
Address1: | 18127 WILLIAM ST | ||||||||
Address2: |   | ||||||||
City: | LANSING | ||||||||
State: | IL | ||||||||
PostalCode: | 604383921 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7088896621 | ||||||||
FaxNumber: | 7088896675 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/03/2014 | ||||||||
LastUpdateDate: | 06/12/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036-149564 | IL | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | PENDING | 01 | IL | MEDICARE | OTHER | 036149564 | 05 | IL |   | MEDICAID |