Healthcare Provider Details

I. General information

NPI: 1427176536
Provider Name (Legal Business Name): PEDIATRIC ASSOCIATES OF LAGRANGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 01/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1495 LAFAYETTE PKWY
LAGRANGE GA
30241-2552
US

IV. Provider business mailing address

1495 LAFAYETTE PKWY
LAGRANGE GA
30241-2552
US

V. Phone/Fax

Practice location:
  • Phone: 706-885-1961
  • Fax: 706-885-1963
Mailing address:
  • Phone: 706-885-1961
  • Fax: 706-885-1963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number038421
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: LISA PHARIS ALLARDICE
Title or Position: OWNER
Credential: MD
Phone: 706-855-1961