Provider Demographics
NPI:1285767434
Name:ATEKHA NEPHROLOGY CLINIC
Entity type:Organization
Organization Name:ATEKHA NEPHROLOGY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:COURAGE
Authorized Official - Middle Name:A
Authorized Official - Last Name:ATEKHA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-764-8396
Mailing Address - Street 1:1030 BERMUDA RUN
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-0858
Mailing Address - Country:US
Mailing Address - Phone:912-764-8396
Mailing Address - Fax:912-764-7188
Practice Address - Street 1:1030 BERMUDA RUN
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-0858
Practice Address - Country:US
Practice Address - Phone:912-764-8396
Practice Address - Fax:912-764-7188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049266207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000933413KMedicaid
GA000933413OMedicaid
GA000933413PMedicaid
GA000933413NMedicaid
GA000933413MMedicaid
GA000933413LMedicaid
GA000933413NMedicaid
GA000933413LMedicaid