NPIMap

Organization Active NPI

West Georgia Medical Center Inc

Doing business as Heart and Vascular Care of Georgia

  • Interventional Cardiology Physician
  • Lagrange, GA
National Provider Identifier
1558592089
Registry record updated Oct 13, 2009
On this page

Key facts

NPPES NPI Registry
Primary specialty
Interventional Cardiology PhysicianTaxonomy code 207RI0011X
License
057240 Issued in GA
Legal business name
WEST GEORGIA MEDICAL CENTER INC
Doing business as
Heart and Vascular Care of Georgia
Practice address
1551 Doctors Dr
BLDG 200
Lagrange, GA 30240-4139
Phone
(706) 884-2641
Fax
(706) 884-2353
NPI assigned
Jul 31, 2009
Organization subpart
Yes
Parent organization
WEST GEORGIA MEDICAL CENTER, INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Oct 13, 2009

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Gerald Fulks
Title
Pres / Ceo
Phone
(706) 882-1411

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Cardiovascular Disease PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207RC0000X 057240 GA
Interventional Cardiology PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207RI0011X 057240 GA Primary

Addresses

Primary practice location

1551 Doctors Dr
BLDG 200
Lagrange, GA 30240-4139

Mailing address

PO Box 435
Lagrange, GA 30241-0008
Phone (706) 884-2641

Other identifiers 2

IdentifierTypeStateIssuer
202I061458OtherGAMEDICARE PTAN
685223213BMedicaidGA

Other names 1

  • HEART AND VASCULAR CARE OF GEORGIA Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20091207000333 GA Part B Supplier - Clinic/Group Practice 9335286160 Receives reassigned benefits from 2 practitioners
3 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Lagrange, GA

Other NPIs on the same Medicare enrollment 3

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Part of
West Georgia Medical Center Inc

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1248998400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1255392000000",
    "number": "1558592089",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 435",
            "city": "LAGRANGE",
            "state": "GA",
            "postal_code": "302410008",
            "telephone_number": "706-884-2641",
            "fax_number": "706-884-2353"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1551 DOCTORS DR",
            "address_2": "BLDG 200",
            "city": "LAGRANGE",
            "state": "GA",
            "postal_code": "302404139",
            "telephone_number": "706-884-2641",
            "fax_number": "706-884-2353"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WEST GEORGIA MEDICAL CENTER INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "WEST GEORGIA MEDICAL CENTER, INC",
        "enumeration_date": "2009-07-31",
        "last_updated": "2009-10-13",
        "status": "A",
        "authorized_official_last_name": "FULKS",
        "authorized_official_first_name": "GERALD",
        "authorized_official_title_or_position": "PRES / CEO",
        "authorized_official_telephone_number": "706-882-1411"
    },
    "taxonomies": [
        {
            "code": "207RC0000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Internal Medicine, Cardiovascular Disease",
            "state": "GA",
            "license": "057240",
            "primary": false
        },
        {
            "code": "207RI0011X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Internal Medicine, Interventional Cardiology",
            "state": "GA",
            "license": "057240",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PTAN",
            "identifier": "202I061458",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "685223213B",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "HEART AND VASCULAR CARE OF GEORGIA",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Lagrange, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 13, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.