Healthcare Provider Details

I. General information

NPI: 1679533012
Provider Name (Legal Business Name): NEPHROLOGY MEDICAL ASSOCIATES OF GEORGIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

880 E 3900 S STE B
SALT LAKE CITY UT
84107-2151
US

IV. Provider business mailing address

PO BOX 2355
TACOMA WA
98401
US

V. Phone/Fax

Practice location:
  • Phone: 801-268-1296
  • Fax: 801-268-0340
Mailing address:
  • Phone: 800-310-4872
  • Fax: 877-328-4923

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. GARY WILLIAM BELL
Title or Position: VICE PRESIDENT & CONTROLLER
Credential:
Phone: 800-310-4872