Provider Demographics
NPI:1790125078
Name:NEPHROLOGY MEDICAL ASSOCIATES OF GEORGIA LLC
Entity Type:Organization
Organization Name:NEPHROLOGY MEDICAL ASSOCIATES OF GEORGIA LLC
Other - Org Name:NORTH FLORIDA KIDNEY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-876-6486
Mailing Address - Street 1:1840 E RAY RD
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85225-8720
Mailing Address - Country:US
Mailing Address - Phone:855-397-0197
Mailing Address - Fax:800-272-6512
Practice Address - Street 1:2216 NW 40TH TER
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-3573
Practice Address - Country:US
Practice Address - Phone:352-888-7500
Practice Address - Fax:352-372-1364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-01
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL274957201Medicaid
FL274957201Medicaid