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General NPI Number Information
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NPI Number | 1548301914
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Entity Type | Organization
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Legal Business Name | GRACE PEDIATRICS, LLC
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Dates
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Enumeration Date | 02/09/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 74186 TALLASSEE HWY SUITE B
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City | WETUMPKA
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State | AL
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Zip | 36092-5643
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Country | US
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Telephone | 334-567-0346
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Fax | 334-567-0855
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Provider Business Mailing Address
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Address Line | 138 BRYAN ST
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City | PRATTVILLE
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State | AL
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Zip | 36066-5348
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Country | US
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Telephone | 334-358-5145
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Fax | 334-358-5145
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Authorized Official
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Title or Position | SINGLE MEMBER
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Name | DR. MICHELLE P MEDINA
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Credential | MD
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Telephone | 334-358-5145
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 22736
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License Number State | AL
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