Provider Demographics
NPI:1558592089
Name:WEST GEORGIA MEDICAL CENTER INC
Entity Type:Organization
Organization Name:WEST GEORGIA MEDICAL CENTER INC
Other - Org Name:HEART AND VASCULAR CARE OF GEORGIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES / CEO
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:
Authorized Official - Last Name:FULKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-882-1411
Mailing Address - Street 1:PO BOX 435
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30241-0008
Mailing Address - Country:US
Mailing Address - Phone:706-884-2641
Mailing Address - Fax:706-884-2353
Practice Address - Street 1:1551 DOCTORS DR
Practice Address - Street 2:BLDG 200
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4139
Practice Address - Country:US
Practice Address - Phone:706-884-2641
Practice Address - Fax:706-884-2353
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST GEORGIA MEDICAL CENTER, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-31
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057240207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Single Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I061458OtherMEDICARE PTAN
GA685223213BMedicaid