Provider Demographics
NPI:1821036278
Name:COBB NEPHROLOGY HYPERTENSION ASSOCIATES, PC
Entity Type:Organization
Organization Name:COBB NEPHROLOGY HYPERTENSION ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:L
Authorized Official - Last Name:WOLLAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-460-2706
Mailing Address - Street 1:3875 AUSTELL RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-1153
Mailing Address - Country:US
Mailing Address - Phone:678-460-2700
Mailing Address - Fax:678-909-3620
Practice Address - Street 1:3875 AUSTELL RD
Practice Address - Street 2:SUITE 101
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1153
Practice Address - Country:US
Practice Address - Phone:678-460-2700
Practice Address - Fax:678-909-3620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000146187CMedicaid
FL300029262CMedicaid
GA000495316AMedicaid
GA300029262IMedicaid
GA000146187BMedicaid
GA300029262BMedicaid
GA000495316BMedicaid
GA03169OtherBCBS GROUP #
GA000146187BMedicaid