Provider Demographics
NPI:1649234139
Name:GRACE, CAROL (MD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:GRACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 E PRESIDENT AVE
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-5599
Mailing Address - Country:US
Mailing Address - Phone:662-377-4685
Mailing Address - Fax:662-377-2755
Practice Address - Street 1:1200 MILITARY ST S
Practice Address - Street 2:BROOKS BUILDING
Practice Address - City:HAMILTON
Practice Address - State:AL
Practice Address - Zip Code:35570-5003
Practice Address - Country:US
Practice Address - Phone:205-921-7602
Practice Address - Fax:205-921-7928
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00025976207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009968725Medicaid
MS03627051Medicaid
MS03627051Medicaid
AL051522664Medicare ID - Type Unspecified