Provider Demographics
NPI:1104370915
Name:GRACE MEDICAL CONSULT
Entity Type:Organization
Organization Name:GRACE MEDICAL CONSULT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ADEWALE
Authorized Official - Middle Name:
Authorized Official - Last Name:ADEFOWOJU
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, APN, PMHNP-BC
Authorized Official - Phone:908-693-5036
Mailing Address - Street 1:40 UNION AVE
Mailing Address - Street 2:3RD FL. STE 301
Mailing Address - City:IRVINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07111-3277
Mailing Address - Country:US
Mailing Address - Phone:973-996-2170
Mailing Address - Fax:
Practice Address - Street 1:40 UNION AVE
Practice Address - Street 2:3RD FL. STE 301
Practice Address - City:IRVINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07111-3277
Practice Address - Country:US
Practice Address - Phone:973-996-2170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-09
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00196200363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty