Provider Demographics
NPI:1285694836
Name:NEPHROLOGY MEDICAL ASSOCIATES OF GEORGIA LLC
Entity type:Organization
Organization Name:NEPHROLOGY MEDICAL ASSOCIATES OF GEORGIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-626-6239
Mailing Address - Street 1:14546 OLD SAINT AUGUSTINE RD STE 301
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-5472
Mailing Address - Country:US
Mailing Address - Phone:303-626-6239
Mailing Address - Fax:866-917-5396
Practice Address - Street 1:1627 COLE BLVD BLDG 18
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80401-3315
Practice Address - Country:US
Practice Address - Phone:303-626-6239
Practice Address - Fax:866-917-5396
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-27
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK8787Medicare PIN