Basic Information
Provider Information | |||||||||
NPI: | 1093775645 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NEPHROLOGY MEDICAL ASSOCIATES OF GEORGIA LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | DAVITA NEPHROLOGY PARTNERS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2355 | ||||||||
Address2: |   | ||||||||
City: | TACOMA | ||||||||
State: | WA | ||||||||
PostalCode: | 98401 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8003104872 | ||||||||
FaxNumber: | 8773284923 | ||||||||
Practice Location | |||||||||
Address1: | 1050 W ELM ST | ||||||||
Address2: | STE 160 | ||||||||
City: | HERMISTON | ||||||||
State: | OR | ||||||||
PostalCode: | 97838 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5415641810 | ||||||||
FaxNumber: | 5415641812 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/27/2006 | ||||||||
LastUpdateDate: | 01/16/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | STRACK | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 3036266103 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
ID | Type | State | Issuer | Description | 277872 | 05 | OR |   | MEDICAID |