Basic Information
| Provider Information | |||||||||
| NPI: | 1285694836 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEPHROLOGY MEDICAL ASSOCIATES OF GEORGIA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14546 OLD SAINT AUGUSTINE RD STE 301 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322585472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036266239 | ||||||||
| FaxNumber: | 8669175396 | ||||||||
| Practice Location | |||||||||
| Address1: | 1627 COLE BLVD BLDG 18 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804013315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036266239 | ||||||||
| FaxNumber: | 8669175396 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2006 | ||||||||
| LastUpdateDate: | 12/01/2011 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3036266239 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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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.