MEDICARE: JACK WORK M.D.

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	015442	GA

General Provider Information

NPI Number	:	1740291178
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK WORK M.D.

Provider Business Mailing Address
First Line	:	552 PONCE DE LEON AVE NE
Second Line	:	DIALYSIS ACCESS CTR OF ATLANTA - NEPHROLOGY
City	:	ATLANTA
State	:	GA
Zip	:	30308-1806
Country	:	US
Telephone Number	:	404-872-3655
Fax Number	:

Provider Business Practice Location Address
First Line	:	552 PONCE DE LEON AVE NE
Second Line	:	DIALYSIS ACCESS CTR OF ATLANTA - NEPHROLOGY
City	:	ATLANTA
State	:	GA
Zip	:	30308-1806
Country	:	US
Telephone Number	:	404-872-3655
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/10/2006
Last Update Date	:	07/08/2007

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