Provider Demographics
NPI:1063693463
Name:SANDERSVILLE HYPERTENSION & NEPHROLOGY PC
Entity type:Organization
Organization Name:SANDERSVILLE HYPERTENSION & NEPHROLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LINUS
Authorized Official - Middle Name:ONYEMAECHI
Authorized Official - Last Name:EJIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-552-1200
Mailing Address - Street 1:516 SPARTA RD
Mailing Address - Street 2:P.O. BOX 761
Mailing Address - City:SANDERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31082-1859
Mailing Address - Country:US
Mailing Address - Phone:478-552-1200
Mailing Address - Fax:478-552-5600
Practice Address - Street 1:516 SPARTA RD
Practice Address - Street 2:
Practice Address - City:SANDERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:31082-1859
Practice Address - Country:US
Practice Address - Phone:478-552-1200
Practice Address - Fax:478-552-5600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050617207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAF56370Medicare UPIN
GAGRP4646Medicare PIN
GA050617Medicare PIN