Provider Demographics
NPI:1588920383
Name:IHS OF GEORGIA, LLC
Entity type:Organization
Organization Name:IHS OF GEORGIA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/COO
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN
Authorized Official - Phone:617-328-7707
Mailing Address - Street 1:6001 BROKEN SOUND PKWY
Mailing Address - Street 2:SUITE 502
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33487-2765
Mailing Address - Country:US
Mailing Address - Phone:561-443-0743
Mailing Address - Fax:561-443-7296
Practice Address - Street 1:3200 COBB GALLERIA PKWY
Practice Address - Street 2:SUITE 228
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-5927
Practice Address - Country:US
Practice Address - Phone:617-328-7707
Practice Address - Fax:617-328-7787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-05
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003131469AMedicaid
GA112860Medicare PIN