=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689827370
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEPHROLOGY MEDICAL ASSOCIATES OF GEORGIA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2008
-----------------------------------------------------
Last Update Date | 01/07/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 638 N WEBB RD SUITE B
-----------------------------------------------------
City | GRAND ISLAND
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68803-4057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-382-0121
-----------------------------------------------------
Fax | 308-382-0572
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2000 16TH ST
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-876-7243
-----------------------------------------------------
Fax | 866-917-5396
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SENIOR VP
-----------------------------------------------------
Name | DERON FRANK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 310-536-2402
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------