Provider Demographics
NPI:1215052261
Name:NORTHWEST NEPHROLOGY CLINIC
Entity type:Organization
Organization Name:NORTHWEST NEPHROLOGY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:A
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-981-2211
Mailing Address - Street 1:5255 SNAPFINGER PARK DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30035-4084
Mailing Address - Country:US
Mailing Address - Phone:770-981-2211
Mailing Address - Fax:
Practice Address - Street 1:5255 SNAPFINGER PARK DR
Practice Address - Street 2:SUITE 110
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30035-4084
Practice Address - Country:US
Practice Address - Phone:770-981-2211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA028761174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000702281GMedicaid
GA103863411BMedicaid
GA300030041BMedicaid
GA103863411AMedicaid
GA000441306EMedicaid
GA39BDBXGMedicare PIN
GA103863411AMedicaid
GA000702281GMedicaid
GACG7081Medicare PIN
GAE62597Medicare UPIN
GA000441306EMedicaid
GA11BDVJVMedicare PIN
GAI12181Medicare UPIN
GA103863411BMedicaid
GAG24703Medicare UPIN