Provider Demographics
NPI:1780851436
Name:GEORGIA RENAL ASSOCIATES, PC
Entity Type:Organization
Organization Name:GEORGIA RENAL ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SRILAKSHMI
Authorized Official - Middle Name:
Authorized Official - Last Name:REBALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-546-7484
Mailing Address - Street 1:PO BOX 7335
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30604-7335
Mailing Address - Country:US
Mailing Address - Phone:706-546-7484
Mailing Address - Fax:706-546-7488
Practice Address - Street 1:1500 OGLETHORPE AVE
Practice Address - Street 2:SUITE 500C
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2179
Practice Address - Country:US
Practice Address - Phone:706-546-7484
Practice Address - Fax:706-546-7488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-13
Last Update Date:2012-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051081207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA261448399AMedicaid
GA39BDCJMMedicare PIN
GA261448399AMedicaid