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General NPI Number Information
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NPI Number | 1912198581
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Entity Type | Organization
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Legal Business Name | SOUTHERN NEPHROLOGY CLINIC LLC
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Dates
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Enumeration Date | 08/07/2007
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Last Update Date | 04/07/2009
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Provider Practice Location Address
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Address Line | 8954 HOSPITAL DR BUILDING C. SUITE 115
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City | DOUGLASVILLE
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State | GA
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Zip | 30134-2272
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Country | US
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Telephone | 770-577-4825
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Fax | 770-577-4827
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Provider Business Mailing Address
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Address Line | PO BOX 385
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City | DOUGLASVILLE
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State | GA
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Zip | 30133-0385
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Country | US
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Telephone | 770-577-4825
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Fax |
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Authorized Official
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Title or Position | OWNER/MANAGER
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Name | RAFIQ M EL HAMMALI
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Credential | M.D.
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Telephone | 770-577-4825
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RN0300X
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Taxonomy Name | Nephrology Physician
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License Number | 057606
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License Number State | GA
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