Provider Demographics
NPI:1356664247
Name:WEST GEORGIA MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:WEST GEORGIA MEDICAL CENTER, INC.
Other - Org Name:WEST GEORGIA MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:N
Authorized Official - Last Name:FULKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-845-3702
Mailing Address - Street 1:1514 VERNON RD
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-4131
Mailing Address - Country:US
Mailing Address - Phone:706-882-1411
Mailing Address - Fax:706-845-8918
Practice Address - Street 1:1514 VERNON RD
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4131
Practice Address - Country:US
Practice Address - Phone:706-882-1411
Practice Address - Fax:706-845-8918
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST GEORGIA MEDICAL CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-03-05
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty