Provider Demographics
NPI:1427176536
Name:PEDIATRIC ASSOCIATES OF LAGRANGE
Entity type:Organization
Organization Name:PEDIATRIC ASSOCIATES OF LAGRANGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:PHARIS
Authorized Official - Last Name:ALLARDICE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-855-1961
Mailing Address - Street 1:1495 LAFAYETTE PKWY
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30241-2552
Mailing Address - Country:US
Mailing Address - Phone:706-885-1961
Mailing Address - Fax:706-885-1963
Practice Address - Street 1:1495 LAFAYETTE PKWY
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30241-2552
Practice Address - Country:US
Practice Address - Phone:706-885-1961
Practice Address - Fax:706-885-1963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038421208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty