Provider Demographics
NPI:1265549893
Name:DUBLIN NEPHROLOGY ASSOCIATES LLC
Entity type:Organization
Organization Name:DUBLIN NEPHROLOGY ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BLAISE
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:WIDMER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-272-9688
Mailing Address - Street 1:107 FAIRVIEW PARK DR
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-2501
Mailing Address - Country:US
Mailing Address - Phone:478-272-9688
Mailing Address - Fax:478-275-9446
Practice Address - Street 1:107 FAIRVIEW PARK DR
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-2501
Practice Address - Country:US
Practice Address - Phone:478-272-9688
Practice Address - Fax:478-275-9446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050097207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6430Medicare PIN