MEDICARE: GRACE IVIE EJAIFE-AUSTIN DPM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213E00000X	Podiatrist	POD001084	GA

General Provider Information

NPI Number	:	1588857304
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRACE IVIE EJAIFE-AUSTIN DPM

Provider Business Mailing Address
First Line	:	1043 N HOUSTON RD
Second Line	:
City	:	WARNER ROBINS
State	:	GA
Zip	:	31093-1505
Country	:	US
Telephone Number	:	478-328-6466
Fax Number	:	478-328-1338

Provider Business Practice Location Address
First Line	:	1043 N HOUSTON RD
Second Line	:
City	:	WARNER ROBINS
State	:	GA
Zip	:	31093-1505
Country	:	US
Telephone Number	:	478-328-6466
Fax Number	:	478-328-1338

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/24/2007
Last Update Date	:	09/11/2007

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