Provider Demographics
NPI:1225394075
Name:GIZELLE MANOAH, PC, INC
Entity Type:Organization
Organization Name:GIZELLE MANOAH, PC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANNE-MARIE
Authorized Official - Middle Name:GIZELLE
Authorized Official - Last Name:GRACIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-243-0220
Mailing Address - Street 1:PO BOX 3122
Mailing Address - Street 2:MEMORIAL STATION
Mailing Address - City:UPPER MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07043-3122
Mailing Address - Country:US
Mailing Address - Phone:973-243-0220
Mailing Address - Fax:
Practice Address - Street 1:59 MAIN ST
Practice Address - Street 2:SUITE 204
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-5341
Practice Address - Country:US
Practice Address - Phone:973-243-0220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GIZELLEMANOAH, PC, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-04-05
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA58440261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6560610Medicaid
NJ6560610Medicaid
NJG04234Medicare UPIN
NJ707706Medicare PIN