Provider Demographics
NPI:1750703781
Name:GRACE PEDIATRICS, PC
Entity type:Organization
Organization Name:GRACE PEDIATRICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDY
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:GHEESLING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-426-7706
Mailing Address - Street 1:807A OAKHURST DR
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-3696
Mailing Address - Country:US
Mailing Address - Phone:706-426-7706
Mailing Address - Fax:706-426-7728
Practice Address - Street 1:807A OAKHURST DR
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3696
Practice Address - Country:US
Practice Address - Phone:706-426-7706
Practice Address - Fax:706-426-7728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-10
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA060584208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty