Basic Information
| Provider Information | |||||||||
| NPI: | 1609221555 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EZEAGU | ||||||||
| FirstName: | RAPHAEL | ||||||||
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| Credential: | MBBS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 509 MED TECH PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376042579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233026565 | ||||||||
| FaxNumber: | 4239522175 | ||||||||
| Practice Location | |||||||||
| Address1: | 4802 10TH AVE | ||||||||
| Address2: | MAIMONIDES MEDICAL CENTER | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112192916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182838000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2016 | ||||||||
| LastUpdateDate: | 09/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | 63181 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
No ID Information.