Healthcare Provider Details

I. General information

NPI: 1679152763
Provider Name (Legal Business Name): BY GRACE MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2021
Last Update Date: 04/06/2021
Certification Date: 03/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001-1003 E PATAPSCO AVE
BALTIMORE MD
21225
US

IV. Provider business mailing address

1001-1003 E PATAPSCO AVE
BALTIMORE MD
21225
US

V. Phone/Fax

Practice location:
  • Phone: 443-694-8208
  • Fax:
Mailing address:
  • Phone: 443-694-8208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. PAMELA DUKES
Title or Position: OWNER
Credential:
Phone: 443-694-8208