MEDICARE: LIFE CYCLE OB/GYN, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	045937	GA

General Provider Information

NPI Number	:	1265702385
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE CYCLE OB/GYN, LLC

Provider Business Mailing Address
First Line	:	2739 FELTON DR
Second Line	:
City	:	EAST POINT
State	:	GA
Zip	:	30344-3603
Country	:	US
Telephone Number	:	404-766-8371
Fax Number	:	404-767-3926

Provider Business Practice Location Address
First Line	:	4720 JONESBORO RD
Second Line	:	SUITE 11
City	:	UNION CITY
State	:	GA
Zip	:	30291-1994
Country	:	US
Telephone Number	:	678-519-5386
Fax Number	:	678-519-5391

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	ANNE SIGOUIN
Credential	:	CNM
Telephone Number	:	404-766-8371

Provider Enumeration Date	:	01/05/2012
Last Update Date	:	01/05/2012

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