Provider Demographics
NPI:1659398600
Name:SOUTHSIDE KIDNEY CLINICS, PC
Entity Type:Organization
Organization Name:SOUTHSIDE KIDNEY CLINICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:A
Authorized Official - Last Name:THORPE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-996-6446
Mailing Address - Street 1:3580 CAMERON PARKWAY
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281
Mailing Address - Country:US
Mailing Address - Phone:770-996-6446
Mailing Address - Fax:770-996-6279
Practice Address - Street 1:3580 CAMERON PARKWAY
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281
Practice Address - Country:US
Practice Address - Phone:770-996-6446
Practice Address - Fax:770-996-6279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP3713Medicare ID - Type Unspecified