=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659713733
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRACE FAMILY PRACTICE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2013
-----------------------------------------------------
Last Update Date | 07/18/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 440 CHARTER BLVD SUITE 3303
-----------------------------------------------------
City | MACON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31210-4857
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-405-0280
-----------------------------------------------------
Fax | 478-405-0290
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 440 CHARTER BLVD SUITE 3303
-----------------------------------------------------
City | MACON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31210-4857
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-405-0280
-----------------------------------------------------
Fax | 478-405-0290
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. CHRISTOPHER B REEVES
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 478-405-0280
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 049604
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------