Basic Information
| Provider Information | |||||||||
| NPI: | 1992367478 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OKON-UMOREN | ||||||||
| FirstName: | ANIEBIETABASI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | ONE FORD PLACE 2E | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138745378 | ||||||||
| FaxNumber: | 3139162018 | ||||||||
| Practice Location | |||||||||
| Address1: | 2799 W GRAND BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139161601 | ||||||||
| FaxNumber: | 3139162018 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2019 | ||||||||
| LastUpdateDate: | 03/09/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 02/17/2020 | ||||||||
| NPIReactivationDate: | 03/09/2020 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 03/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4351044811 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.