Provider Demographics
NPI:1538101282
Name:GEISEN, AMY GRACE (MD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:GRACE
Last Name:GEISEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 95000 LB# 7550
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19195-7550
Mailing Address - Country:US
Mailing Address - Phone:844-362-1735
Mailing Address - Fax:973-290-7495
Practice Address - Street 1:212 STATE RT 94
Practice Address - Street 2:SUITE 1C
Practice Address - City:VERNON
Practice Address - State:NJ
Practice Address - Zip Code:07462-3328
Practice Address - Country:US
Practice Address - Phone:973-823-8800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2018-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08070700207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTI48685Medicare UPIN