Provider Demographics
NPI:1023058898
Name:SPALDING COUNTY DIALYSIS, LLC
Entity type:Organization
Organization Name:SPALDING COUNTY DIALYSIS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMAD
Authorized Official - Middle Name:MOUSSA
Authorized Official - Last Name:KASSEM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-467-8116
Mailing Address - Street 1:744 S 8TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-4827
Mailing Address - Country:US
Mailing Address - Phone:770-467-8116
Mailing Address - Fax:770-467-8795
Practice Address - Street 1:744 S 8TH ST STE 100
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4827
Practice Address - Country:US
Practice Address - Phone:770-467-8116
Practice Address - Fax:770-467-8795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAESRD001194261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00946613AMedicaid
GA00946613AMedicaid