Healthcare Provider Details

I. General information

NPI: 1285844498
Provider Name (Legal Business Name): SOUTHERN CENTER FOR WOMENS HEALTH PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 01/25/2022
Certification Date: 01/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 S LEWIS ST
LAGRANGE GA
30240-3144
US

IV. Provider business mailing address

310 S LEWIS ST
LAGRANGE GA
30240-3144
US

V. Phone/Fax

Practice location:
  • Phone: 706-845-0500
  • Fax: 706-812-9315
Mailing address:
  • Phone: 706-845-0500
  • Fax: 706-812-9315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number043546
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JAMES J BENDELL
Title or Position: PHYSICIAN
Credential: MD
Phone: 706-845-0500