MEDICARE: SOUTH ATLANTA KIDNEY CARE DIALYSIS

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	052252	GA
2	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center	112780	GA

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	:	1891712766
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH ATLANTA KIDNEY CARE DIALYSIS

Provider Business Mailing Address
First Line	:	195 UPPER RIVERDALE RD SUITE A
Second Line	:
City	:	RIVERDALE
State	:	GA
Zip	:	30274
Country	:	US
Telephone Number	:	770-994-0171
Fax Number	:	770-507-4190

Provider Business Practice Location Address
First Line	:	2221 PEACHTREE RD NE
Second Line	:	SUITE D 195
City	:	ATLANTA
State	:	GA
Zip	:	30309-1148
Country	:	US
Telephone Number	:	770-994-0171
Fax Number	:	770-507-4190

Authorized Official
Title or Position	:	PHYSICIAN-MEDICAL DIRECTOR
Name	:	WAINDEL BELIZAIRE
Credential	:	D.O
Telephone Number	:	770-994-0171

Provider Enumeration Date	:	07/16/2006
Last Update Date	:	07/13/2008

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