Provider Demographics
NPI:1689827370
Name:NEPHROLOGY MEDICAL ASSOCIATES OF GEORGIA LLC
Entity Type:Organization
Organization Name:NEPHROLOGY MEDICAL ASSOCIATES OF GEORGIA LLC
Other - Org Name:NEBRASKA KIDNEY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VP
Authorized Official - Prefix:
Authorized Official - First Name:DERON
Authorized Official - Middle Name:
Authorized Official - Last Name:FRANK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-536-2402
Mailing Address - Street 1:2000 16TH ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80202
Mailing Address - Country:US
Mailing Address - Phone:303-876-7243
Mailing Address - Fax:866-917-5396
Practice Address - Street 1:638 N WEBB RD
Practice Address - Street 2:SUITE B
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4057
Practice Address - Country:US
Practice Address - Phone:308-382-0121
Practice Address - Fax:308-382-0572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-28
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025674900Medicaid
NENA1229Medicare PIN