MEDICARE: GWINNETT NEPHROLOGY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RN0300X	Nephrology Physician

General Provider Information

NPI Number	:	1053968511
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GWINNETT NEPHROLOGY LLC

Provider Business Mailing Address
First Line	:	1567 JANMAR RD STE 100
Second Line	:
City	:	SNELLVILLE
State	:	GA
Zip	:	30078-0308
Country	:	US
Telephone Number	:	470-310-3179
Fax Number	:

Provider Business Practice Location Address
First Line	:	1567 JANMAR RD STE 100
Second Line	:
City	:	SNELLVILLE
State	:	GA
Zip	:	30078-0308
Country	:	US
Telephone Number	:	470-310-3179
Fax Number	:

Authorized Official
Title or Position	:	MD/OWNER
Name	:	JITHENDRANATH REDDY PALACHERLA
Credential	:	MD
Telephone Number	:	470-310-3179

Provider Enumeration Date	:	08/20/2019
Last Update Date	:	08/20/2019

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