Provider Demographics
NPI:1902085582
Name:PATRICK IFEDIBA MD LLC
Entity Type:Organization
Organization Name:PATRICK IFEDIBA MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:EMEKA
Authorized Official - Last Name:IFEDIBA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:205-929-0565
Mailing Address - Street 1:PO BOX 59472
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35259-9472
Mailing Address - Country:US
Mailing Address - Phone:205-929-0565
Mailing Address - Fax:205-929-0564
Practice Address - Street 1:1300 BESSEMER RD
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35208-4326
Practice Address - Country:US
Practice Address - Phone:205-929-0565
Practice Address - Fax:205-929-0564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-30
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL19014207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51000499OtherBLUE CROSS
AL051554814Medicaid
AL051554814Medicaid
ALG07774Medicare UPIN