MEDICARE: IHS OF GEORGIA, LLC

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	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588920383
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IHS OF GEORGIA, LLC

Provider Business Mailing Address
First Line	:	6001 BROKEN SOUND PKWY
Second Line	:	SUITE 502
City	:	BOCA RATON
State	:	FL
Zip	:	33487-2765
Country	:	US
Telephone Number	:	561-443-0743
Fax Number	:	561-443-7296

Provider Business Practice Location Address
First Line	:	3200 COBB GALLERIA PKWY
Second Line	:	SUITE 228
City	:	ATLANTA
State	:	GA
Zip	:	30339-5927
Country	:	US
Telephone Number	:	617-328-7707
Fax Number	:	617-328-7787

Authorized Official
Title or Position	:	PRESIDENT/COO
Name	:	MRS. KATHLEEN MCDONNELL
Credential	:	RN, BSN
Telephone Number	:	617-328-7707

Provider Enumeration Date	:	04/05/2012
Last Update Date	:	01/22/2015

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