Provider Demographics
NPI:1285881508
Name:GENESIS NEPHROLOGY, LLC
Entity type:Organization
Organization Name:GENESIS NEPHROLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARISA
Authorized Official - Middle Name:TURNER
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-221-2707
Mailing Address - Street 1:1560 IRVING PL
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4604
Mailing Address - Country:US
Mailing Address - Phone:318-221-2707
Mailing Address - Fax:318-221-2709
Practice Address - Street 1:1560 IRVING PL
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4604
Practice Address - Country:US
Practice Address - Phone:318-221-2707
Practice Address - Fax:318-221-2709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-19
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA023908207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAH46621Medicare UPIN