1811938277 NPI number — STOCKBRIDGE DIALYSIS CLINIC, 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 1811938277 NPI number — STOCKBRIDGE DIALYSIS CLINIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STOCKBRIDGE DIALYSIS CLINIC, 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:
1811938277
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:
3588 HIGHWAY 138 SE
Provider Second Line Business Mailing Address:
PMB 344
Provider Business Mailing Address City Name:
STOCKBRIDGE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30281-4171
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-565-6228
Provider Business Mailing Address Fax Number:
770-565-6246

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7444 HANNOVER PKWY S
Provider Second Line Business Practice Location Address:
SUITE 270
Provider Business Practice Location Address City Name:
STOCKBRIDGE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30281-9303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-565-6228
Provider Business Practice Location Address Fax Number:
678-565-6246
Provider Enumeration Date:
06/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KASSEM
Authorized Official First Name:
MOHAMAD
Authorized Official Middle Name:
MOUSSA
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
678-565-6228

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X , with the licence number:  ESRD001247 , 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)





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