Provider Demographics
NPI:1861719601
Name:JOSIAH EKUNNO MEDICAL CORPORATION
Entity type:Organization
Organization Name:JOSIAH EKUNNO MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSIAH
Authorized Official - Middle Name:O
Authorized Official - Last Name:EKUNNO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-355-6218
Mailing Address - Street 1:11125 DUNN RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-6132
Mailing Address - Country:US
Mailing Address - Phone:314-355-6218
Mailing Address - Fax:314-355-1092
Practice Address - Street 1:11125 DUNN RD
Practice Address - Street 2:SUITE 202
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6132
Practice Address - Country:US
Practice Address - Phone:314-355-6218
Practice Address - Fax:314-355-1092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-03
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO35803174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200927101Medicaid
MO200927101Medicaid
MO000001064Medicare PIN