Healthcare Provider Details

I. General information

NPI: 1700526142
Provider Name (Legal Business Name): J & G FAMILY PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2022
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9331 LIBERTY RD # 2C
RANDALLSTOWN MD
21133-3525
US

IV. Provider business mailing address

9331 LIBERTY RD # 2C
RANDALLSTOWN MD
21133-3525
US

V. Phone/Fax

Practice location:
  • Phone: 410-701-8485
  • Fax: 410-701-8524
Mailing address:
  • Phone: 410-701-8485
  • Fax: 410-701-8524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: NGUM AVWONTOM
Title or Position: PRESIDENT
Credential: FNP-BC
Phone: 301-404-1989