Provider Demographics
NPI:1669590725
Name:CHRISTIAN M EZEKWUECHE
Entity type:Organization
Organization Name:CHRISTIAN M EZEKWUECHE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:PANETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-741-5155
Mailing Address - Street 1:770 PINE ST
Mailing Address - Street 2:SUITE 560
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-2173
Mailing Address - Country:US
Mailing Address - Phone:478-741-5155
Mailing Address - Fax:478-746-9682
Practice Address - Street 1:770 PINE ST
Practice Address - Street 2:SUITE 560
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2173
Practice Address - Country:US
Practice Address - Phone:478-741-5155
Practice Address - Fax:478-746-9682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056574174400000X
GA024808174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00259949AMedicaid
GA00259949AMedicaid
GAD29428Medicare UPIN
GAGRP7408Medicare ID - Type Unspecified