1053416925 NPI number — NORTH GEORGIA KIDNEY SPECIALISTS, LLC

Table of content: (NPI 1053416925)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053416925 NPI number — NORTH GEORGIA KIDNEY SPECIALISTS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTH GEORGIA KIDNEY SPECIALISTS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053416925
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/15/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
880 CANTON RD NE
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
MARIETTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30060-7283
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-528-9788
Provider Business Mailing Address Fax Number:
770-420-2229

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
880 CANTON RD NE
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
MARIETTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30060-7283
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-528-9788
Provider Business Practice Location Address Fax Number:
770-420-2229
Provider Enumeration Date:
09/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GALLEGO
Authorized Official First Name:
MANOLO
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PRESIDENT/PHYSICIAN
Authorized Official Telephone Number:
770-528-9788

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X , with the licence number:  036745 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1285688283 . This is a "MUHAMMAD YASSER JABRI, M.D. INDIVIDUAL NPI #" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 233167541A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 555189352A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: DD6106 . This is a "MEDICARE RAILROAD GROUP #" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 00691182AB , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 282117409A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000960726F , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1275520793 . This is a "GALLEGO INDIVIDUAL NPI" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com