Provider Demographics
NPI:1619919966
Name:GEORGIA NEPHROLOGY, LLC
Entity Type:Organization
Organization Name:GEORGIA NEPHROLOGY, LLC
Other - Org Name:SOUTH DEKALB DIALYSIS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-981-0558
Mailing Address - Street 1:2801 CANDLER RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-1423
Mailing Address - Country:US
Mailing Address - Phone:404-241-0402
Mailing Address - Fax:404-328-0232
Practice Address - Street 1:2801 CANDLER RD
Practice Address - Street 2:SUITE 203
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034-1423
Practice Address - Country:US
Practice Address - Phone:404-241-0402
Practice Address - Fax:404-328-0232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAESRD001212261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00963168A/BMedicaid
GA112715Medicare ID - Type UnspecifiedESRD CLINIC