1588690887 NPI number — NEPHROLOGY MEDICAL ASSOCIATES OF GEORGIA, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588690887 NPI number — NEPHROLOGY MEDICAL ASSOCIATES OF GEORGIA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEPHROLOGY MEDICAL ASSOCIATES OF GEORGIA, 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:
6
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:
1588690887
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2000 16TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DENVER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-876-7253
Provider Business Mailing Address Fax Number:
866-917-5396

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15895 SW 72ND AVE STE 250
Provider Second Line Business Practice Location Address:
BLDG B
Provider Business Practice Location Address City Name:
TIGARD
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97224-7966
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-624-5630
Provider Business Practice Location Address Fax Number:
503-624-9149
Provider Enumeration Date:
06/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FRANK
Authorized Official First Name:
DERON
Authorized Official Middle Name:
Authorized Official Title or Position:
GENERAL MANAGER, VICE PRESIDENT
Authorized Official Telephone Number:
310-536-2402

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: OMAP006021 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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