1558418921 NPI number — DOUGLASVILLE NEPHROLOGY & HTN CLINIC

Table of content: (NPI 1558418921)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558418921 NPI number — DOUGLASVILLE NEPHROLOGY & HTN CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DOUGLASVILLE NEPHROLOGY & HTN CLINIC
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:
1558418921
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/14/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6488 SPRING ST STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOUGLASVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30134-1895
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-489-4978
Provider Business Mailing Address Fax Number:
770-489-5279

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6488 SPRING ST STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOUGLASVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30134-1895
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-489-4978
Provider Business Practice Location Address Fax Number:
770-489-5279
Provider Enumeration Date:
01/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SMALLS
Authorized Official First Name:
DOREEN
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
770-489-4978

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  40859 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RN0300X , with the licence number: 40859 , 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)

  • Identifier: 00693877R , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00693877V , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 12085 . This is a "COVENTRY" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 6443 . This is a "KAISER PERMANENTE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 00693877L , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00693877M , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10038018 . This is a "AMERIGROUP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 303395 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 006937877P , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00693877P , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00693877Z , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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