Basic Information
| Provider Information | |||||||||
| NPI: | 1790125078 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEPHROLOGY MEDICAL ASSOCIATES OF GEORGIA LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NORTH FLORIDA KIDNEY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1840 E RAY RD | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852258720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8553970197 | ||||||||
| FaxNumber: | 8002726512 | ||||||||
| Practice Location | |||||||||
| Address1: | 2216 NW 40TH TER | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326053573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3528887500 | ||||||||
| FaxNumber: | 3523721364 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2013 | ||||||||
| LastUpdateDate: | 02/06/2020 | ||||||||
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| AuthorizedOfficialLastName: | PETERSON | ||||||||
| AuthorizedOfficialFirstName: | JENNIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3038766486 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/06/2020 | ||||||||
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 | 274957201 | 05 | FL | MEDICAID |