MEDICARE: WEST GEORGIA MEDICAL GROUP-LAGRANGE

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	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1831422484
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST GEORGIA MEDICAL GROUP-LAGRANGE

Provider Business Mailing Address
First Line	:	142 OLD MILL RD
Second Line	:
City	:	LAGRANGE
State	:	GA
Zip	:	30241-6704
Country	:	US
Telephone Number	:	706-882-7440
Fax Number	:	706-882-1350

Provider Business Practice Location Address
First Line	:	142 OLD MILL RD
Second Line	:
City	:	LAGRANGE
State	:	GA
Zip	:	30241-6704
Country	:	US
Telephone Number	:	706-882-7440
Fax Number	:	706-882-1350

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ANDRE DIOSDADO FERIA
Credential	:	M.D.
Telephone Number	:	706-882-7440

Provider Enumeration Date	:	09/15/2009
Last Update Date	:	09/15/2009

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