Healthcare Provider Details

I. General information

NPI: 1164711792
Provider Name (Legal Business Name): WEST GEORGIA HEALTH PHYSICIANS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2011
Last Update Date: 08/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1514 VERNON RD
LAGRANGE GA
30240-4131
US

IV. Provider business mailing address

PO BOX 1483
COLUMBUS GA
31902-1483
US

V. Phone/Fax

Practice location:
  • Phone: 706-882-1411
  • Fax:
Mailing address:
  • Phone: 706-882-1411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 10
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. GERALD N FULKS
Title or Position: DIRECTOR
Credential:
Phone: 706-882-1411