MEDICARE: TALLADEGA 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	21771	AL

General Provider Information

NPI Number	:	1982800884
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TALLADEGA NEPHROLOGY, LLC

Provider Business Mailing Address
First Line	:	210 NORTH ST W
Second Line	:
City	:	TALLADEGA
State	:	AL
Zip	:	35160-2083
Country	:	US
Telephone Number	:	256-521-1996
Fax Number	:

Provider Business Practice Location Address
First Line	:	210 NORTH ST W
Second Line	:
City	:	TALLADEGA
State	:	AL
Zip	:	35160-2083
Country	:	US
Telephone Number	:	256-521-1996
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ANDRE D FERIA
Credential	:	M.D.
Telephone Number	:	256-521-1997

Provider Enumeration Date	:	06/26/2007
Last Update Date	:	08/22/2020

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