Provider Demographics
NPI:1003856840
Name:BARNESVILLE DIALYSIS, LLC
Entity Type:Organization
Organization Name:BARNESVILLE DIALYSIS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMAD
Authorized Official - Middle Name:MOUSSA
Authorized Official - Last Name:KASSEM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-358-1142
Mailing Address - Street 1:3588 HIGHWAY 138 SE
Mailing Address - Street 2:PMB 344
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-4171
Mailing Address - Country:US
Mailing Address - Phone:770-358-1142
Mailing Address - Fax:770-358-1503
Practice Address - Street 1:783 HIGHWAY 341 S
Practice Address - Street 2:
Practice Address - City:BARNESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30204-3793
Practice Address - Country:US
Practice Address - Phone:770-358-1142
Practice Address - Fax:770-358-1503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAESRD001248261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA112757Medicare ID - Type Unspecified