1669607891 NPI number — WEST GEORGIA FAMILY PRACTICE P.C

Table of content: (NPI 1669607891)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669607891 NPI number — WEST GEORGIA FAMILY PRACTICE P.C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WEST GEORGIA FAMILY PRACTICE P.C
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669607891
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/16/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301 MEDICAL DR
Provider Second Line Business Mailing Address:
SUITE 503
Provider Business Mailing Address City Name:
LAGRANGE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30240-4144
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-882-2447
Provider Business Mailing Address Fax Number:
706-882-2473

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 MEDICAL DR
Provider Second Line Business Practice Location Address:
SUITE 503
Provider Business Practice Location Address City Name:
LAGRANGE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30240-4144
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-867-7630
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/18/2009

Additional Information

Authorized Official

Authorized Official Last Name:
BRAMHADEVI
Authorized Official First Name:
SRINIVAS RAO
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
678-867-7630

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  061946 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com