Provider Demographics
NPI:1962825844
Name:GEORGIA KIDNEY INSTITUTE LLC
Entity Type:Organization
Organization Name:GEORGIA KIDNEY INSTITUTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MORUFU
Authorized Official - Middle Name:
Authorized Official - Last Name:ALAUSA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-714-7171
Mailing Address - Street 1:PO BOX 3134
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60434-3134
Mailing Address - Country:US
Mailing Address - Phone:815-714-7171
Mailing Address - Fax:
Practice Address - Street 1:1625 HARDEMAN AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-1417
Practice Address - Country:US
Practice Address - Phone:478-257-5200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-28
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055819261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1962825844OtherNPI
GA003124971AMedicaid
GA003124971AMedicaid