MEDICARE: BIRTH BY GRACE MIDWIFERY SERVICES, 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	261QB0400X	Birthing Clinic/Center	RN241382	GA

General Provider Information

NPI Number	:	1447624234
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BIRTH BY GRACE MIDWIFERY SERVICES, LLC

Provider Business Mailing Address
First Line	:	3832 RIDGEWOOD DR SE
Second Line	:
City	:	SMYRNA
State	:	GA
Zip	:	30080-5926
Country	:	US
Telephone Number	:	773-304-7925
Fax Number	:

Provider Business Practice Location Address
First Line	:	3832 RIDGEWOOD DR SE
Second Line	:
City	:	SMYRNA
State	:	GA
Zip	:	30080-5926
Country	:	US
Telephone Number	:	773-304-7925
Fax Number	:

Authorized Official
Title or Position	:	CNM/OWNER
Name	:	CHRISTINE TAYLOR
Credential	:	CNM
Telephone Number	:	773-304-7925

Provider Enumeration Date	:	11/17/2015
Last Update Date	:	11/17/2015

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