Provider Demographics
NPI:1730326778
Name:WEST GEORGIA NEUROLOGY AND NEURODIAGNOSTICS, P.C.
Entity type:Organization
Organization Name:WEST GEORGIA NEUROLOGY AND NEURODIAGNOSTICS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLO PRACTITIONER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:A
Authorized Official - Last Name:CANEDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-571-0121
Mailing Address - Street 1:2300 MANCHESTER EXPY
Mailing Address - Street 2:ST FRANCIS MEDICAL PARK, H-103
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-6802
Mailing Address - Country:US
Mailing Address - Phone:706-571-0121
Mailing Address - Fax:706-571-0124
Practice Address - Street 1:2300 MANCHESTER EXPY
Practice Address - Street 2:ST FRANCIS MEDICAL PARK, H-103
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-6802
Practice Address - Country:US
Practice Address - Phone:706-571-0121
Practice Address - Fax:706-571-0124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-13
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2084N0400X261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000416435AMedicaid
AL009304610Medicaid
GAC74411Medicare UPIN