Provider Demographics
NPI:1588690887
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 MANAGER, VICE PRESIDENT
Authorized Official - Prefix:
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
Mailing Address - Country:US
Mailing Address - Phone:303-876-7253
Mailing Address - Fax:866-917-5396
Practice Address - Street 1:15895 SW 72ND AVE STE 250
Practice Address - Street 2:BLDG B
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-7966
Practice Address - Country:US
Practice Address - Phone:503-624-5630
Practice Address - Fax:503-624-9149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OROMAP006021Medicaid
ORR134795Medicare PIN