Provider Demographics
NPI:1720035819
Name:NRA MIDTOWN MACON GEORGIA LLC
Entity Type:Organization
Organization Name:NRA MIDTOWN MACON GEORGIA LLC
Other - Org Name:MIDTOWN MACON DIALYSIS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:M
Authorized Official - Last Name:SUNDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-507-3307
Mailing Address - Street 1:1550 W. MCEWEN DRIVE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-1731
Mailing Address - Country:US
Mailing Address - Phone:615-661-1100
Mailing Address - Fax:615-507-3300
Practice Address - Street 1:657 HEMLOCK ST
Practice Address - Street 2:SUITE 100
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-8329
Practice Address - Country:US
Practice Address - Phone:478-742-8001
Practice Address - Fax:478-742-3608
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NRA II, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-27
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11D1048766OtherCLIA CERTIFICATE OF WAIVE
GA655442926AMedicaid
GA655442926AMedicaid