Basic Information
Provider Information | |||||||||
NPI: | 1184650517 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NEPHROLOGY MEDICAL ASSOCIATES OF GEORGIA, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SAINT CHARLES NEPHROLOGY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1832 CENTRE POINT CIR | ||||||||
Address2: | SUITE 106 | ||||||||
City: | NAPERVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 605631438 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6308368724 | ||||||||
FaxNumber: | 8665949002 | ||||||||
Practice Location | |||||||||
Address1: | 1207 STATE ROUTE VV | ||||||||
Address2: |   | ||||||||
City: | KENNETT | ||||||||
State: | MO | ||||||||
PostalCode: | 638573823 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6369700249 | ||||||||
FaxNumber: | 6369700269 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/25/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BEIL | ||||||||
AuthorizedOfficialFirstName: | GARY | ||||||||
AuthorizedOfficialMiddleName: | W. | ||||||||
AuthorizedOfficialTitleorPosition: | VP CONTROLLER | ||||||||
AuthorizedOfficialTelephone: | 2533821910 | ||||||||
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 |
No ID Information.