Basic Information
| Provider Information | |||||||||
| NPI: | 1083803472 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NEPHROLOGY INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | KIDNEY CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1425 HIGHWAY 34 E | ||||||||
| Address2: | |||||||||
| City: | NEWNAN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302651323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703043724 | ||||||||
| FaxNumber: | 7703043726 | ||||||||
| Practice Location | |||||||||
| Address1: | 1425 HIGHWAY 34 E | ||||||||
| Address2: | |||||||||
| City: | NEWNAN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302651323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703043724 | ||||||||
| FaxNumber: | 7703043726 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2007 | ||||||||
| LastUpdateDate: | 10/31/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GIVENS | ||||||||
| AuthorizedOfficialFirstName: | RACHEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 7703043724 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 048905 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 300044734C | 05 | GA | MEDICAID |