Healthcare Provider Details

I. General information

NPI: 1548301914
Provider Name (Legal Business Name): GRACE PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74186 TALLASSEE HWY SUITE B
WETUMPKA AL
36092-5643
US

IV. Provider business mailing address

138 BRYAN ST
PRATTVILLE AL
36066-5348
US

V. Phone/Fax

Practice location:
  • Phone: 334-567-0346
  • Fax: 334-567-0855
Mailing address:
  • Phone: 334-358-5145
  • Fax: 334-358-5145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number22736
License Number StateAL

VIII. Authorized Official

Name: DR. MICHELLE P MEDINA
Title or Position: SINGLE MEMBER
Credential: MD
Phone: 334-358-5145