MEDICARE: CHAMPION HEALTHCARE AND NEPHROLOGY, 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	207RN0300X	Nephrology Physician	48067	GA

General Provider Information

NPI Number	:	1902080062
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHAMPION HEALTHCARE AND NEPHROLOGY, LLC

Provider Business Mailing Address
First Line	:	7525 COVINGTON HWY
Second Line	:	SUITE D
City	:	LITHONIA
State	:	GA
Zip	:	30058-7439
Country	:	US
Telephone Number	:	770-484-4842
Fax Number	:	770-484-9595

Provider Business Practice Location Address
First Line	:	7525 COVINGTON HWY
Second Line	:	SUITE D
City	:	LITHONIA
State	:	GA
Zip	:	30058-7439
Country	:	US
Telephone Number	:	770-484-4842
Fax Number	:	770-484-9595

Authorized Official
Title or Position	:	OWNER/CEO
Name	:	DR. MARY ARDESAR MORROW
Credential	:	M.D.
Telephone Number	:	770-484-4842

Provider Enumeration Date	:	12/26/2007
Last Update Date	:	12/26/2007

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