Basic Information
| Provider Information | |||||||||
| NPI: | 1588690887 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEPHROLOGY MEDICAL ASSOCIATES OF GEORGIA, LLC | ||||||||
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| OtherOrganizationName: | OREGON KIDNEY AND HYPERTENSION CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 16TH ST | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3038767253 | ||||||||
| FaxNumber: | 8669175396 | ||||||||
| Practice Location | |||||||||
| Address1: | 15895 SW 72ND AVE STE 250 | ||||||||
| Address2: | BLDG B | ||||||||
| City: | TIGARD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972247966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036245630 | ||||||||
| FaxNumber: | 5036249149 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2006 | ||||||||
| LastUpdateDate: | 09/13/2012 | ||||||||
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| AuthorizedOfficialLastName: | FRANK | ||||||||
| AuthorizedOfficialFirstName: | DERON | ||||||||
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| AuthorizedOfficialTitleorPosition: | GENERAL MANAGER, VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3105362402 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | OMAP006021 | 05 | OR | MEDICAID |