Provider Demographics
NPI: | 1487229639 |
---|---|
Name: | GRACE MEDICAL SERVICES LLC |
Entity Type: | Organization |
Organization Name: | GRACE MEDICAL SERVICES LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER OF ENTITY |
Authorized Official - Prefix: | |
Authorized Official - First Name: | AGATHA |
Authorized Official - Middle Name: | N |
Authorized Official - Last Name: | UKAEGBU |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MSN |
Authorized Official - Phone: | 443-275-1031 |
Mailing Address - Street 1: | 6600 YORK RD STE 200B |
Mailing Address - Street 2: | |
Mailing Address - City: | BALTIMORE |
Mailing Address - State: | MD |
Mailing Address - Zip Code: | 21212-2024 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 443-275-1031 |
Mailing Address - Fax: | 443-275-2597 |
Practice Address - Street 1: | 6600 YORK RD STE 200B |
Practice Address - Street 2: | |
Practice Address - City: | BALTIMORE |
Practice Address - State: | MD |
Practice Address - Zip Code: | 21212-2024 |
Practice Address - Country: | US |
Practice Address - Phone: | 443-275-1031 |
Practice Address - Fax: | 443-275-2597 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2021-05-20 |
Last Update Date: | 2021-05-24 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 363LP2300X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | Group - Multi-Specialty |