Provider Demographics
NPI:1093974578
Name:WEST GA FAMILY MEDICINE, PC
Entity Type:Organization
Organization Name:WEST GA FAMILY MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:NEWTON
Authorized Official - Last Name:LANGFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:770-222-5488
Mailing Address - Street 1:1899 LAKE RD
Mailing Address - Street 2:212
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-2291
Mailing Address - Country:US
Mailing Address - Phone:770-222-5488
Mailing Address - Fax:770-222-5491
Practice Address - Street 1:1899 LAKE RD
Practice Address - Street 2:212
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-2291
Practice Address - Country:US
Practice Address - Phone:770-222-5488
Practice Address - Fax:770-222-5491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-09
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA045867207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000816923CMedicaid
GA000816923CMedicaid