Provider Demographics
NPI:1437229309
Name:NEPHROLOGY & HYPERTENSION MEDICAL ASSOCIATES, PC
Entity Type:Organization
Organization Name:NEPHROLOGY & HYPERTENSION MEDICAL ASSOCIATES, PC
Other - Org Name:NEPHROLOGY AND ENDOCRINOLGY CONSULTANTS
Other - Org Type:Other Name
Authorized Official - Title/Position:OPERATION MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRISH
Authorized Official - Middle Name:G
Authorized Official - Last Name:ROTUREAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-650-5450
Mailing Address - Street 1:208 SCRANTON CONNECTOR
Mailing Address - Street 2:SUITE 117
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31525-0559
Mailing Address - Country:US
Mailing Address - Phone:912-264-5961
Mailing Address - Fax:912-262-9499
Practice Address - Street 1:111 COLONIAL WAY STE 2
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31545-0132
Practice Address - Country:US
Practice Address - Phone:912-588-1919
Practice Address - Fax:912-354-7569
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA026402207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000291079QMedicaid
GA630423104AMedicaid
GA000291079AMedicaid
GAGRP2930OtherMEDICARE GROUP
GA000291079MMedicaid
GA000291079ZMedicaid
GA000291079OMedicaid
GA000291079KMedicaid
GA630423104CMedicaid
GAGRP2930Medicare PIN
GA630423104CMedicaid
GA000291079KMedicaid
GAGRP2930OtherMEDICARE GROUP
GAE01061Medicare UPIN
GA97BBCRRMedicare ID - Type UnspecifiedBETH RESPESS PA
GA630423104CMedicaid