1790706455 NPI number — RENAL HYPERTENSION CLINIC PC

Table of content: (NPI 1790706455)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790706455 NPI number — RENAL HYPERTENSION CLINIC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RENAL HYPERTENSION CLINIC PC
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:
1790706455
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/10/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2650
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOUGLAS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31534-2650
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-384-7210
Provider Business Mailing Address Fax Number:
912-384-5130

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
190 WESTSIDE DR
Provider Second Line Business Practice Location Address:
B
Provider Business Practice Location Address City Name:
DOUGLAS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31533-3533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-384-7210
Provider Business Practice Location Address Fax Number:
912-384-5130
Provider Enumeration Date:
07/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SARMA
Authorized Official First Name:
AKKARAJU
Authorized Official Middle Name:
V.S.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
912-384-7210

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: 00257463E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00257463A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com