Provider Demographics
NPI:1841230174
Name:NEPHROLOGY MEDICAL ASSOCIATES OF GEORGIA LLC
Entity type:Organization
Organization Name:NEPHROLOGY MEDICAL ASSOCIATES OF GEORGIA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT & CONTROLLER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:E
Authorized Official - Last Name:GABRIEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-626-6000
Mailing Address - Street 1:1627 COLE BLVD BLDG 182ND
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80401-3315
Mailing Address - Country:US
Mailing Address - Phone:303-626-6000
Mailing Address - Fax:866-352-3987
Practice Address - Street 1:170 CAMDEN HILL RD
Practice Address - Street 2:SUITE F
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-7418
Practice Address - Country:US
Practice Address - Phone:770-339-4225
Practice Address - Fax:770-339-4797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300043495AMedicaid
GAGRP4296Medicare ID - Type Unspecified