Provider Demographics
NPI:1558403113
Name:CARROLL COUNTY NEPHROLOGY PC
Entity Type:Organization
Organization Name:CARROLL COUNTY NEPHROLOGY PC
Other - Org Name:CARROLL COUNTY NEPHROLOGY LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:BILLING & CODING
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:V
Authorized Official - Last Name:BEASLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-832-0429
Mailing Address - Street 1:157 CLINIC AVENUE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117
Mailing Address - Country:US
Mailing Address - Phone:770-832-0429
Mailing Address - Fax:770-838-9108
Practice Address - Street 1:157 CLINIC AVENUE
Practice Address - Street 2:SUITE 203
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117
Practice Address - Country:US
Practice Address - Phone:770-832-0429
Practice Address - Fax:770-838-9108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
39BDBXNMedicare PIN