Healthcare Provider Details

I. General information

NPI: 1871874859
Provider Name (Legal Business Name): EZE FAMILY HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2011
Last Update Date: 10/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11750 BUSINESS PARK DR SUITE 103
WALDORF MD
20601-2907
US

IV. Provider business mailing address

11750 BUSINESS PARK DR SUITE 103
WALDORF MD
20601-2907
US

V. Phone/Fax

Practice location:
  • Phone: 301-323-3921
  • Fax: 888-519-5179
Mailing address:
  • Phone: 301-323-3921
  • Fax: 888-519-5179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberD69441
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberD0037088
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC0004111
License Number StateMD

VIII. Authorized Official

Name: CHINYERE EZE
Title or Position: MEDICAL PRACTITIONER / CEO
Credential: PA-C
Phone: 301-323-3921