Basic Information
| Provider Information | |||||||||
| NPI: | 1831562958 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ATLANTA KIDNEY CARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5667 PEACHTREE DUNWOODY RD STE 260 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042551030 | ||||||||
| FaxNumber: | 6027988267 | ||||||||
| Practice Location | |||||||||
| Address1: | 5667 PEACHTREE DUNWOODY RD STE 260 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042551030 | ||||||||
| FaxNumber: | 6027988267 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2015 | ||||||||
| LastUpdateDate: | 10/07/2021 | ||||||||
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| AuthorizedOfficialLastName: | HILL | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 4806397185 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/07/2021 | ||||||||
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 | 003181580A | 05 | GA | MEDICAID |