MEDICARE: LAFAYETTE NEUROLOGY, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084N0400X	Neurology Physician	58107	GA

General Provider Information

NPI Number	:	1164882635
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAFAYETTE NEUROLOGY, PC

Provider Business Mailing Address
First Line	:	1075 LAFAYETTE PARKWAY
Second Line	:	SUITE 210
City	:	LAGRANGE
State	:	GA
Zip	:	30241-3584
Country	:	US
Telephone Number	:	706-350-5525
Fax Number	:	706-350-5295

Provider Business Practice Location Address
First Line	:	1075 LAFAYETTE PARKWAY
Second Line	:	SUITE 210
City	:	LAGRANGE
State	:	GA
Zip	:	30241-3584
Country	:	US
Telephone Number	:	706-350-5525
Fax Number	:	706-350-5295

Authorized Official
Title or Position	:	OFFICE MGR.
Name	:	RAMONA BURNSIDE
Credential	:
Telephone Number	:	706-350-5525

Provider Enumeration Date	:	02/26/2016
Last Update Date	:	08/14/2018

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