Provider Demographics
NPI:1548501380
Name:LAGRANGE PRIMARY CARE PC
Entity type:Organization
Organization Name:LAGRANGE PRIMARY CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VISHWAS
Authorized Official - Middle Name:
Authorized Official - Last Name:KADAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-923-9486
Mailing Address - Street 1:25 TURNBERRY CIR
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-4154
Mailing Address - Country:US
Mailing Address - Phone:678-923-9486
Mailing Address - Fax:678-401-0292
Practice Address - Street 1:505 JENKINS ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4225
Practice Address - Country:US
Practice Address - Phone:678-923-9486
Practice Address - Fax:678-401-0292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-04
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA062529207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty