Provider Demographics
NPI:1215128186
Name:EAST GEORGIA NEPHROLOGY, PC
Entity type:Organization
Organization Name:EAST GEORGIA NEPHROLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:912-871-2200
Mailing Address - Street 1:450 GEORGIA AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-5585
Mailing Address - Country:US
Mailing Address - Phone:912-871-2200
Mailing Address - Fax:912-871-2220
Practice Address - Street 1:450 GEORGIA AVE
Practice Address - Street 2:SUITE B
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-5585
Practice Address - Country:US
Practice Address - Phone:912-871-2200
Practice Address - Fax:912-871-2220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-06
Last Update Date:2015-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034372207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GADN3298OtherRAILROAD MEDICARE
GA300034644AMedicaid
GAGRP4589Medicare PIN