Basic Information
| Provider Information | |||||||||
| NPI: | 1982667069 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NNEBE | ||||||||
| FirstName: | NKIRUKA | ||||||||
| MiddleName: | SANDRA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NNEBE | ||||||||
| OtherFirstName: | SANDRA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2500 MARYLAND RD STE 504 | ||||||||
| Address2: | |||||||||
| City: | WILLOW GROVE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190901226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154816836 | ||||||||
| FaxNumber: | 2154815788 | ||||||||
| Practice Location | |||||||||
| Address1: | 10800 KNIGHTS RD | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191144200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156124000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2006 | ||||||||
| LastUpdateDate: | 12/10/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/10/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD426961 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | MD426961 | PA | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 95398 | 01 | PA | GEISINGER HEALTH PLAN | OTHER | NN1757955 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 1014682300001 | 05 | PA | MEDICAID | 50054406 | 01 | PA | CAPITAL BLUE CROSS | OTHER | P00268548 | 01 | PA | RAILROAD MEDICARE | OTHER |