Provider Demographics
NPI:1972935898
Name:GRACEFUL GYNECOLOGY, INC.
Entity Type:Organization
Organization Name:GRACEFUL GYNECOLOGY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:COX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-845-4000
Mailing Address - Street 1:2114 GAULT AVE N
Mailing Address - Street 2:
Mailing Address - City:FORT PAYNE
Mailing Address - State:AL
Mailing Address - Zip Code:35967-3534
Mailing Address - Country:US
Mailing Address - Phone:256-845-4000
Mailing Address - Fax:
Practice Address - Street 1:2114 GAULT AVE N
Practice Address - Street 2:
Practice Address - City:FORT PAYNE
Practice Address - State:AL
Practice Address - Zip Code:35967
Practice Address - Country:US
Practice Address - Phone:256-845-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-01
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL23680261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALH47024Medicare UPIN