Basic Information
| Provider Information | |||||||||
| NPI: | 1679533012 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEPHROLOGY MEDICAL ASSOCIATES OF GEORGIA LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DAVITA NEPHROLOGY PARTNERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2355 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003104872 | ||||||||
| FaxNumber: | 8773284923 | ||||||||
| Practice Location | |||||||||
| Address1: | 880 E 3900 S | ||||||||
| Address2: | STE B | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841072151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012681296 | ||||||||
| FaxNumber: | 8012680340 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BELL | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | WILLIAM | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT & CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 8003104872 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207R00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | W0522 | 05 | UT | MEDICAID |