Provider Demographics
NPI:1518012863
Name:LAGRANGE OBSTETRICS & GYNECOLOGY
Entity Type:Organization
Organization Name:LAGRANGE OBSTETRICS & GYNECOLOGY
Other - Org Name:HAVEN GYNECOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:CHADWICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:706-812-2229
Mailing Address - Street 1:307 CHURCH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-2700
Mailing Address - Country:US
Mailing Address - Phone:706-812-2229
Mailing Address - Fax:706-882-6455
Practice Address - Street 1:307 CHURCH ST
Practice Address - Street 2:SUITE A
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-2700
Practice Address - Country:US
Practice Address - Phone:706-812-2229
Practice Address - Fax:706-882-6455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA16BDSWDMedicare PIN