Provider Demographics
NPI:1659713733
Name:GRACE FAMILY PRACTICE
Entity Type:Organization
Organization Name:GRACE FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:B
Authorized Official - Last Name:REEVES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-405-0280
Mailing Address - Street 1:440 CHARTER BLVD
Mailing Address - Street 2:SUITE 3303
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-4857
Mailing Address - Country:US
Mailing Address - Phone:478-405-0280
Mailing Address - Fax:478-405-0290
Practice Address - Street 1:440 CHARTER BLVD
Practice Address - Street 2:SUITE 3303
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-4857
Practice Address - Country:US
Practice Address - Phone:478-405-0280
Practice Address - Fax:478-405-0290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-18
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049604207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA998226OtherBCBS
GA000925955BMedicaid
GAP00348683OtherRAILROAD MEDICARE
GAP00348683OtherRAILROAD MEDICARE