Provider Demographics
NPI:1093800823
Name:EJESE HEALTHCARE, PC
Entity Type:Organization
Organization Name:EJESE HEALTHCARE, PC
Other - Org Name:EJESE URGENT CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING CONTACT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:K
Authorized Official - Last Name:IRUNGU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-456-6118
Mailing Address - Street 1:125 COMMONS WAY STE 203
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-7041
Mailing Address - Country:US
Mailing Address - Phone:770-456-6118
Mailing Address - Fax:770-456-6227
Practice Address - Street 1:125 COMMONS WAY STE 203
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-7041
Practice Address - Country:US
Practice Address - Phone:770-456-6118
Practice Address - Fax:770-456-6227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055684207Q00000X
207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAH84201Medicare UPIN
GAGRP7676Medicare ID - Type Unspecified