Provider Demographics
NPI:1407091887
Name:LAGRANGE CARDIOVASCULAR CENTER LLC
Entity Type:Organization
Organization Name:LAGRANGE CARDIOVASCULAR CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LINUS
Authorized Official - Middle Name:ADAH
Authorized Official - Last Name:WODI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-883-7341
Mailing Address - Street 1:301 MEDICAL DR
Mailing Address - Street 2:SUITE 506
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-4144
Mailing Address - Country:US
Mailing Address - Phone:706-883-7341
Mailing Address - Fax:706-883-7572
Practice Address - Street 1:301 MEDICAL DR
Practice Address - Street 2:SUITE 506
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4144
Practice Address - Country:US
Practice Address - Phone:706-883-7341
Practice Address - Fax:706-883-7572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-12
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA061683207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAH72604Medicare UPIN