MEDICARE: SANDERSVILLE HYPERTENSION & NEPHROLOGY PC

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	050617	GA

General Provider Information

NPI Number	:	1063693463
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SANDERSVILLE HYPERTENSION & NEPHROLOGY PC

Provider Business Mailing Address
First Line	:	516 SPARTA RD
Second Line	:	P.O. BOX 761
City	:	SANDERSVILLE
State	:	GA
Zip	:	31082-1859
Country	:	US
Telephone Number	:	478-552-1200
Fax Number	:	478-552-5600

Provider Business Practice Location Address
First Line	:	516 SPARTA RD
Second Line	:
City	:	SANDERSVILLE
State	:	GA
Zip	:	31082-1859
Country	:	US
Telephone Number	:	478-552-1200
Fax Number	:	478-552-5600

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. LINUS ONYEMAECHI EJIM
Credential	:	M.D.
Telephone Number	:	478-552-1200

Provider Enumeration Date	:	11/14/2007
Last Update Date	:	01/18/2013

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