Provider Demographics
NPI:1053439174
Name:GYNECOLOGY & OBSTETRICS PROFESSIONAL GROUP OF WEST GEORGIA PC
Entity type:Organization
Organization Name:GYNECOLOGY & OBSTETRICS PROFESSIONAL GROUP OF WEST GEORGIA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:BRANDI
Authorized Official - Middle Name:L
Authorized Official - Last Name:KNOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-884-6026
Mailing Address - Street 1:1602 VERNON RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-4129
Mailing Address - Country:US
Mailing Address - Phone:706-884-6026
Mailing Address - Fax:706-884-0433
Practice Address - Street 1:1602 VERNON RD STE 200
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4129
Practice Address - Country:US
Practice Address - Phone:706-884-6026
Practice Address - Fax:706-884-0433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA16BDTHFMedicare ID - Type UnspecifiedSAMUEL JONES MILLER
GAI07980Medicare UPIN
GAF43088Medicare UPIN
GA16BBCJCMedicare ID - Type UnspecifiedBRETT ASHLEY BOWIE