Provider Demographics
NPI:1497372064
Name:GEORGIA MEDICAL AND NEPHROLOGY GROUP
Entity Type:Organization
Organization Name:GEORGIA MEDICAL AND NEPHROLOGY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CYRIACUS
Authorized Official - Middle Name:
Authorized Official - Last Name:ANAELE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-226-4053
Mailing Address - Street 1:4450 CALIBRE XING NW STE 1126
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-4104
Mailing Address - Country:US
Mailing Address - Phone:770-226-4053
Mailing Address - Fax:
Practice Address - Street 1:4450 CALIBRE XING NW STE 1126
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-4104
Practice Address - Country:US
Practice Address - Phone:770-226-4053
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-30
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty