Provider Demographics
NPI:1093887168
Name:GRACE MEDICAL CLINIC
Entity Type:Organization
Organization Name:GRACE MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:EHI
Authorized Official - Middle Name:PHILIP
Authorized Official - Last Name:OSEHOBO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-688-1155
Mailing Address - Street 1:230 W COLLEGE ST
Mailing Address - Street 2:B
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-4121
Mailing Address - Country:US
Mailing Address - Phone:678-688-1155
Mailing Address - Fax:678-688-5071
Practice Address - Street 1:230 W COLLEGE ST
Practice Address - Street 2:B
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4121
Practice Address - Country:US
Practice Address - Phone:678-688-1155
Practice Address - Fax:678-688-5071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049075207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA187778601AMedicaid
GAH33567Medicare UPIN
GA11BDWWZMedicare ID - Type Unspecified