1619919966 NPI number — GEORGIA NEPHROLOGY, LLC

Table of content: (NPI 1619919966)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619919966 NPI number — GEORGIA NEPHROLOGY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEORGIA NEPHROLOGY, 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:
SOUTH DEKALB DIALYSIS CENTER
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:
1619919966
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2801 CANDLER RD
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
DECATUR
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30034-1423
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-241-0402
Provider Business Mailing Address Fax Number:
404-328-0232

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2801 CANDLER RD
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
DECATUR
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30034-1423
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-241-0402
Provider Business Practice Location Address Fax Number:
404-328-0232
Provider Enumeration Date:
06/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DIXON
Authorized Official First Name:
ANDREW
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/CEO
Authorized Official Telephone Number:
770-981-0558

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X , with the licence number:  ESRD001212 , 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: 00963168A/B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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