Provider Demographics
NPI:1801420948
Name:AMAZING GRACE MEDICAL CENTER LLC
Entity type:Organization
Organization Name:AMAZING GRACE MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EBERE
Authorized Official - Middle Name:
Authorized Official - Last Name:EZEANYA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-704-5644
Mailing Address - Street 1:4995 DERBY LN
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18020-9418
Mailing Address - Country:US
Mailing Address - Phone:973-704-5644
Mailing Address - Fax:
Practice Address - Street 1:445 MARSHALL ST
Practice Address - Street 2:
Practice Address - City:PHILLIPSBURG
Practice Address - State:NJ
Practice Address - Zip Code:08865-2695
Practice Address - Country:US
Practice Address - Phone:609-582-0899
Practice Address - Fax:833-957-0121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-27
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty