NPIMap

Organization Active NPI

Eastside Premier Nephrology & Hypertension PC

  • Nephrology Physician
  • Conyers, GA
National Provider Identifier
1104048651
Registry record updated Mar 22, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Nephrology PhysicianTaxonomy code 207RN0300X
License
044714 Issued in GA
Legal business name
EASTSIDE PREMIER NEPHROLOGY & HYPERTENSION PC
Practice address
1612 Milstead Rd NE
Suite a
Conyers, GA 30012-3738
Phone
(678) 413-3261
Fax
(678) 413-3580
NPI assigned
May 3, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 22, 2011

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Oladapo Falase
Title
Office Manager
Phone
(678) 413-3261

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Nephrology PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207RN0300X 044714 GA Primary

Addresses

Primary practice location

1612 Milstead Rd NE
Suite a
Conyers, GA 30012-3738

Mailing address

PO Box 1157
Covington, GA 30015-1157
Phone (678) 413-3261

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20110608000776 GA Part B Supplier - Clinic/Group Practice 5991735037 Receives reassigned benefits from 3 practitioners
Practice locations: Decatur, GA; Stonecrest, GA; Conyers, GA

National Provider Directory

National Provider Directory

Member organizations 2

Organizations listed as members of this organization in the National Provider Directory.

Locations

1612 Milstead Rd NE
#A
Conyers, GA 30012
Phone (678) 413-3261

4570 Memorial Dr
Ste B
Decatur, GA 30032
Phone (404) 720-8154

2161 W Spring St
Monroe, GA 30655
Phone (770) 267-4470

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1178150400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1300752000000",
    "number": "1104048651",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1157",
            "city": "COVINGTON",
            "state": "GA",
            "postal_code": "300151157",
            "telephone_number": "678-413-3261",
            "fax_number": "678-413-3580"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1612 MILSTEAD RD NE",
            "address_2": "SUITE A",
            "city": "CONYERS",
            "state": "GA",
            "postal_code": "300123738",
            "telephone_number": "678-413-3261",
            "fax_number": "678-413-3580"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EASTSIDE PREMIER NEPHROLOGY & HYPERTENSION PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-05-03",
        "last_updated": "2011-03-22",
        "status": "A",
        "authorized_official_last_name": "FALASE",
        "authorized_official_first_name": "OLADAPO",
        "authorized_official_title_or_position": "OFFICE MANAGER",
        "authorized_official_telephone_number": "678-413-3261",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "207RN0300X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Internal Medicine, Nephrology",
            "state": "GA",
            "license": "044714",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Conyers, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 22, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.