Provider Demographics
NPI:1932183654
Name:GEORGIA KIDNEY ASSOCIATES, INC.
Entity Type:Organization
Organization Name:GEORGIA KIDNEY ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:HIMOT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-427-7389
Mailing Address - Street 1:55 WHITCHER ST NE
Mailing Address - Street 2:SUITE 460
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1155
Mailing Address - Country:US
Mailing Address - Phone:770-427-7389
Mailing Address - Fax:770-427-2845
Practice Address - Street 1:55 WHITCHER ST NE
Practice Address - Street 2:SUITE 460
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1155
Practice Address - Country:US
Practice Address - Phone:770-427-7389
Practice Address - Fax:770-427-2845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-06
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300023127XMedicaid
GA300023127XMedicaid