Basic Information
| Provider Information | |||||||||
| NPI: | 1932412509 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EZIDINMA | ||||||||
| FirstName: | AFOMA | ||||||||
| MiddleName: | PHOEBE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | EZIDINMA | ||||||||
| OtherFirstName: | PHOEBE | ||||||||
| OtherMiddleName: | A. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 836 W WELLINGTON AVE | ||||||||
| Address2: | # 1423 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606575147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083642200 | ||||||||
| FaxNumber: | 6083637395 | ||||||||
| Practice Location | |||||||||
| Address1: | 5605 E ROCKTON RD | ||||||||
| Address2: | NORTHPOINTE CLINIC | ||||||||
| City: | ROSCOE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610737601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8155254500 | ||||||||
| FaxNumber: | 8155254505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2010 | ||||||||
| LastUpdateDate: | 12/27/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036122956 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | 036-122956 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 208M00000X | 036122956 | IL | N | Allopathic & Osteopathic Physicians | Hospitalist | 207RC0000X | 56346-20 | WI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.