1104872647 NPI number — HYPERTENSION & KIDNEY,PC

Table of content: (NPI 1104872647)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104872647 NPI number — HYPERTENSION & KIDNEY,PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HYPERTENSION & KIDNEY,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:
1104872647
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/11/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1126
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAWRENCEVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30046-1126
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-513-3565
Provider Business Mailing Address Fax Number:
770-513-1924

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
134 S CLAYTON ST
Provider Second Line Business Practice Location Address:
SUIT # 8
Provider Business Practice Location Address City Name:
LAWRENCEVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30046-5753
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-513-3565
Provider Business Practice Location Address Fax Number:
770-513-1924
Provider Enumeration Date:
05/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HUSSAIN
Authorized Official First Name:
NABILA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
770-513-3565

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  051765 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RN0300X , with the licence number: 051765 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 553623912A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000967095E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000967095G , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000967095C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000967095J , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000967095K , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000967095B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000967095H , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000967095F , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000967095I , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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