Healthcare Provider Details

I. General information

NPI: 1639948722
Provider Name (Legal Business Name): GENESIS BIRTH CONCEPTS INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2023
Last Update Date: 03/17/2025
Certification Date: 03/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2788 BAYARD ST STE 100
ATLANTA GA
30344-3440
US

IV. Provider business mailing address

2788 BAYARD ST
EAST POINT GA
30344-3441
US

V. Phone/Fax

Practice location:
  • Phone: 404-218-9496
  • Fax:
Mailing address:
  • Phone: 404-291-8028
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number
License Number State

VIII. Authorized Official

Name: TIARA MACK
Title or Position: NP
Credential: FNP
Phone: 404-291-8028