Basic Information
| Provider Information | |||||||||
| NPI: | 1528680543 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EZEMA MED SERVICES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 27 NASHAWAY DR | ||||||||
| Address2: | |||||||||
| City: | RINGOES | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 085512056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9083384626 | ||||||||
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| Practice Location | |||||||||
| Address1: | 27 NASHAWAY DR | ||||||||
| Address2: | |||||||||
| City: | RINGOES | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 085512056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9083384626 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2020 | ||||||||
| LastUpdateDate: | 05/13/2020 | ||||||||
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| AuthorizedOfficialLastName: | EZEMA | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9083384626 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 05/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 6862004 | 05 | NJ | MEDICAID |