=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639948722
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GENESIS BIRTH CONCEPTS INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/29/2023
-----------------------------------------------------
Last Update Date | 03/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2788 BAYARD ST STE 100
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30344-3440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-218-9496
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2788 BAYARD ST
-----------------------------------------------------
City | EAST POINT
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30344-3441
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-291-8028
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NP
-----------------------------------------------------
Name | TIARA MACK
-----------------------------------------------------
Credential | FNP
-----------------------------------------------------
Telephone | 404-291-8028
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207VX0000X
-----------------------------------------------------
Taxonomy Name | Obstetrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------