Healthcare Provider Details

I. General information

NPI: 1265671457
Provider Name (Legal Business Name): HOSPITALIST AT FAIRVIEW PARK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2009
Last Update Date: 02/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 INDUSTRIAL BLVD
DUBLIN GA
31021-2981
US

IV. Provider business mailing address

200 INDUSTRIAL BLVD
DUBLIN GA
31021-2981
US

V. Phone/Fax

Practice location:
  • Phone: 478-274-3747
  • Fax: 478-274-3663
Mailing address:
  • Phone: 478-274-3747
  • Fax: 478-274-3663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN LAVERTY
Title or Position: VP
Credential:
Phone: 615-507-2312