Provider Demographics
NPI:1417664616
Name:GEORGIA KIDNEY CLINIC LLC
Entity Type:Organization
Organization Name:GEORGIA KIDNEY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RIYADH
Authorized Official - Middle Name:R
Authorized Official - Last Name:AL-RUBAYE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:047-316-0334
Mailing Address - Street 1:2725 HAMILTON MILL RD STE 500
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-6010
Mailing Address - Country:US
Mailing Address - Phone:404-731-6033
Mailing Address - Fax:
Practice Address - Street 1:3382 GRACE FARM LN
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30519
Practice Address - Country:US
Practice Address - Phone:404-731-6033
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-28
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
No261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) TreatmentGroup - Single Specialty