1184650517 NPI number — NEPHROLOGY MEDICAL ASSOCIATES OF GEORGIA, LLC

Table of content: (NPI 1184650517)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184650517 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:
1184650517
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:
1832 CENTRE POINT CIR
Provider Second Line Business Mailing Address:
SUITE 106
Provider Business Mailing Address City Name:
NAPERVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60563-1438
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-836-8724
Provider Business Mailing Address Fax Number:
866-594-9002

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1207 STATE ROUTE VV
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENNETT
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63857-3823
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-970-0249
Provider Business Practice Location Address Fax Number:
636-970-0269
Provider Enumeration Date:
06/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BEIL
Authorized Official First Name:
GARY
Authorized Official Middle Name:
W.
Authorized Official Title or Position:
VP CONTROLLER
Authorized Official Telephone Number:
253-382-1910

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)





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