Provider Demographics
NPI:1679533012
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:GARY
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:BELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-310-4872
Mailing Address - Street 1:PO BOX 2355
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98401
Mailing Address - Country:US
Mailing Address - Phone:800-310-4872
Mailing Address - Fax:877-328-4923
Practice Address - Street 1:880 E 3900 S
Practice Address - Street 2:STE B
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-2151
Practice Address - Country:US
Practice Address - Phone:801-268-1296
Practice Address - Fax:801-268-0340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTW0522Medicaid
UT=========001Medicaid