Provider Demographics
NPI:1811159718
Name:THE KIDNEY CLINIC
Entity type:Organization
Organization Name:THE KIDNEY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MAZEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:ABDALLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-344-0334
Mailing Address - Street 1:2386 CLOWER ST
Mailing Address - Street 2:SUITE C-105
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-6134
Mailing Address - Country:US
Mailing Address - Phone:678-344-0334
Mailing Address - Fax:678-344-0343
Practice Address - Street 1:2386 CLOWER ST STE C105
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-6107
Practice Address - Country:US
Practice Address - Phone:678-344-0334
Practice Address - Fax:678-344-0343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-01
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038414261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1467420893OtherNPI FOR MAZEN ABDALLA,MD
GA00612752AMedicaid
GAF60925Medicare UPIN