Provider Demographics
NPI:1093775645
Name:NEPHROLOGY MEDICAL ASSOCIATES OF GEORGIA LLC
Entity Type:Organization
Organization Name:NEPHROLOGY MEDICAL ASSOCIATES OF GEORGIA LLC
Other - Org Name:DAVITA NEPHROLOGY PARTNERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:STRACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-626-6103
Mailing Address - Street 1:PO BOX 2355
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98401
Mailing Address - Country:US
Mailing Address - Phone:800-310-4872
Mailing Address - Fax:877-328-4923
Practice Address - Street 1:1050 W ELM ST
Practice Address - Street 2:STE 160
Practice Address - City:HERMISTON
Practice Address - State:OR
Practice Address - Zip Code:97838
Practice Address - Country:US
Practice Address - Phone:541-564-1810
Practice Address - Fax:541-564-1812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-27
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR277872Medicaid
OR277872Medicaid