Provider Demographics
NPI:1558418921
Name:DOUGLASVILLE NEPHROLOGY & HTN CLINIC
Entity Type:Organization
Organization Name:DOUGLASVILLE NEPHROLOGY & HTN CLINIC
Other - Org Name:DOUGLASVILLE NEPHROLOGY
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DOREEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMALLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-489-4978
Mailing Address - Street 1:6488 SPRING ST STE 100
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-1895
Mailing Address - Country:US
Mailing Address - Phone:770-489-4978
Mailing Address - Fax:770-489-5279
Practice Address - Street 1:6488 SPRING ST STE 100
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-1895
Practice Address - Country:US
Practice Address - Phone:770-489-4978
Practice Address - Fax:770-489-5279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA40859174400000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00693877RMedicaid
GA00693877VMedicaid
GA12085OtherCOVENTRY
GA6443OtherKAISER PERMANENTE
GA00693877LMedicaid
GA00693877MMedicaid
GA10038018OtherAMERIGROUP
GA303395OtherWELLCARE
GA006937877PMedicaid
GA00693877PMedicaid
GA00693877ZMedicaid
GA6443OtherKAISER PERMANENTE
GA00693877PMedicaid
GA303395OtherWELLCARE
GA10038018OtherAMERIGROUP
GACJ9541Medicare ID - Type UnspecifiedRAILROAD MEDICARE
GA00693877LMedicaid