Healthcare Provider Details

I. General information

NPI: 1134076359
Provider Name (Legal Business Name): GRACEWAY HEALTH CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2026
Last Update Date: 03/27/2026
Certification Date: 03/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10259 CABERY RD
ELLICOTT CITY MD
21042-1605
US

IV. Provider business mailing address

115 E MELROSE AVE
BALTIMORE MD
21212-2945
US

V. Phone/Fax

Practice location:
  • Phone: 410-870-9380
  • Fax:
Mailing address:
  • Phone: 410-435-9073
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State

VIII. Authorized Official

Name: ADDISU M. TEMESGEN
Title or Position: MD
Credential: MD
Phone: 410-435-9073