1083803472 NPI number — NEPHROLOGY INC

Table of content: EMILY CHAN MD, PHD (NPI 1053495168)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083803472 NPI number — NEPHROLOGY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEPHROLOGY INC
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:
KIDNEY CLINIC
Provider Other Organization Name Type Code:
3
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:
1083803472
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/31/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1425 HIGHWAY 34 E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWNAN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30265-1323
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-304-3724
Provider Business Mailing Address Fax Number:
770-304-3726

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1425 HIGHWAY 34 E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWNAN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30265-1323
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-304-3724
Provider Business Practice Location Address Fax Number:
770-304-3726
Provider Enumeration Date:
10/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GIVENS
Authorized Official First Name:
RACHEL
Authorized Official Middle Name:
Authorized Official Title or Position:
AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
770-304-3724

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X , with the licence number:  048905 , 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: 300044734C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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