Provider Demographics
NPI:1407192172
Name:NEPHROLOGY MEDICAL ASSOCIATES OF GEORGIA, LLC
Entity Type:Organization
Organization Name:NEPHROLOGY MEDICAL ASSOCIATES OF GEORGIA, LLC
Other - Org Name:SOUTHERN KIDNEY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JENNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-983-1120
Mailing Address - Street 1:1840 E. RAY ROAD
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85225
Mailing Address - Country:US
Mailing Address - Phone:205-354-2100
Mailing Address - Fax:866-343-6766
Practice Address - Street 1:3570 GRANDVIEW PKWY STE 2
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35243-2064
Practice Address - Country:US
Practice Address - Phone:205-354-2100
Practice Address - Fax:866-343-6766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL102G703618Medicare PIN