Provider Demographics
NPI:1912198581
Name:SOUTHERN NEPHROLOGY CLINIC LLC
Entity Type:Organization
Organization Name:SOUTHERN NEPHROLOGY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RAFIQ
Authorized Official - Middle Name:M
Authorized Official - Last Name:EL HAMMALI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-577-4825
Mailing Address - Street 1:PO BOX 385
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30133-0385
Mailing Address - Country:US
Mailing Address - Phone:770-577-4825
Mailing Address - Fax:
Practice Address - Street 1:8954 HOSPITAL DR
Practice Address - Street 2:BUILDING C. SUITE 115
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-2272
Practice Address - Country:US
Practice Address - Phone:770-577-4825
Practice Address - Fax:770-577-4827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-07
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057606207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty