Provider Demographics
NPI:1508058066
Name:LAFAYETTE FAMILY PRACTICE
Entity Type:Organization
Organization Name:LAFAYETTE FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:706-638-5300
Mailing Address - Street 1:611 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LA FAYETTE
Mailing Address - State:GA
Mailing Address - Zip Code:30728-2241
Mailing Address - Country:US
Mailing Address - Phone:706-638-5300
Mailing Address - Fax:706-638-5323
Practice Address - Street 1:611 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LA FAYETTE
Practice Address - State:GA
Practice Address - Zip Code:30728-2241
Practice Address - Country:US
Practice Address - Phone:706-638-5300
Practice Address - Fax:706-638-5323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-17
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA22056207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty