Provider Demographics
NPI:1548301914
Name:GRACE PEDIATRICS, LLC
Entity type:Organization
Organization Name:GRACE PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SINGLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:P
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-358-5145
Mailing Address - Street 1:138 BRYAN ST
Mailing Address - Street 2:
Mailing Address - City:PRATTVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36066-5348
Mailing Address - Country:US
Mailing Address - Phone:334-358-5145
Mailing Address - Fax:334-358-5145
Practice Address - Street 1:74186 TALLASSEE HWY
Practice Address - Street 2:SUITE B
Practice Address - City:WETUMPKA
Practice Address - State:AL
Practice Address - Zip Code:36092-5643
Practice Address - Country:US
Practice Address - Phone:334-567-0346
Practice Address - Fax:334-567-0855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL22736208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty