Provider Demographics
NPI:1295882454
Name:MEDICAL KIDNEY SERVICES OF CENTRAL GEORGIA, LTD.
Entity type:Organization
Organization Name:MEDICAL KIDNEY SERVICES OF CENTRAL GEORGIA, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:C
Authorized Official - Last Name:ROWLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-453-2031
Mailing Address - Street 1:PO BOX 4207
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31208-4207
Mailing Address - Country:US
Mailing Address - Phone:478-453-2031
Mailing Address - Fax:
Practice Address - Street 1:521 W MONTGOMERY ST
Practice Address - Street 2:#14A
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-3293
Practice Address - Country:US
Practice Address - Phone:478-453-2031
Practice Address - Fax:478-452-5225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA112544Medicare ID - Type Unspecified