Provider Demographics
NPI:1902802515
Name:EHIRIM, PRINCEWILL U (MD)
Entity Type:Individual
Prefix:DR
First Name:PRINCEWILL
Middle Name:U
Last Name:EHIRIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:500 MEDICAL CENTER BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-8708
Mailing Address - Country:US
Mailing Address - Phone:678-916-7053
Mailing Address - Fax:678-826-0867
Practice Address - Street 1:500 MEDICAL CENTER BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-8708
Practice Address - Country:US
Practice Address - Phone:678-916-7053
Practice Address - Fax:678-826-0867
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-28
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA048508207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00890326BMedicaid
GA00890326BMedicaid
GAH15611Medicare UPIN