Provider Demographics
NPI:1285674515
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:GENERAL MANGER/VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DERON
Authorized Official - Middle Name:
Authorized Official - Last Name:FRANK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-536-2402
Mailing Address - Street 1:2000 16TH ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80202-5117
Mailing Address - Country:US
Mailing Address - Phone:303-876-7243
Mailing Address - Fax:866-917-5396
Practice Address - Street 1:307 N 46TH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68503-3714
Practice Address - Country:US
Practice Address - Phone:402-466-8259
Practice Address - Fax:866-891-4864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025093700Medicaid
NE10025093700Medicaid