1093775645 NPI number — NEPHROLOGY MEDICAL ASSOCIATES OF GEORGIA LLC

Table of content: (NPI 1093775645)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093775645 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:
1093775645
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2355
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-310-4872
Provider Business Mailing Address Fax Number:
877-328-4923

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1050 W ELM ST
Provider Second Line Business Practice Location Address:
STE 160
Provider Business Practice Location Address City Name:
HERMISTON
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97838
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-564-1810
Provider Business Practice Location Address Fax Number:
541-564-1812
Provider Enumeration Date:
03/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
STRACK
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
303-626-6103

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: 277872 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com