Provider Demographics
NPI:1831267632
Name:LAGRANGE INTERNAL MEDICINE, PC
Entity type:Organization
Organization Name:LAGRANGE INTERNAL MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:E
Authorized Official - Last Name:GARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:706-298-2640
Mailing Address - Street 1:1602 VERNON RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-4129
Mailing Address - Country:US
Mailing Address - Phone:706-882-9341
Mailing Address - Fax:706-884-0131
Practice Address - Street 1:1602 VERNON RD
Practice Address - Street 2:SUITE 400
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4129
Practice Address - Country:US
Practice Address - Phone:706-882-9341
Practice Address - Fax:706-884-0131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP930Medicare ID - Type UnspecifiedMEDICARE GROUP PROVIDER #