=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215052261
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHWEST NEPHROLOGY CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2007
-----------------------------------------------------
Last Update Date | 03/08/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5255 SNAPFINGER PARK DR SUITE 110
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30035-4084
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-981-2211
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5255 SNAPFINGER PARK DR SUITE 110
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30035-4084
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-981-2211
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | ANDREW A DIXON
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 770-981-2211
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 028761
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------