NPIMap

Individual provider Active NPI

Kimathi Sipho Ricardo Blackwood, M.D.

  • Nephrology Physician
  • Macon, GA
National Provider Identifier
1609071448
Registry record updated Jun 21, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Nephrology PhysicianTaxonomy code 207RN0300X
License
063834 Issued in GA
Practice address
890 Second Street
Suite 201
Macon, GA 31201-6863
Phone
(478) 745-4322
Fax
(478) 750-8789
NPI assigned
Jun 20, 2007
Last updated
Jun 21, 2022By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jun 21, 2022

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

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Student in an Organized Health Care Education/Training Program 390200000X NU
Nephrology Physician 207RN0300X 063834 GA Primary

Addresses

Primary practice location

890 Second Street
Suite 201
Macon, GA 31201-6863

Mailing address

595 Hurricane Shoals Rd NW Ste 100
Lawrenceville, GA 30046-8762
Phone (404) 645-7150

Other identifiers 2

IdentifierTypeStateIssuer
546478200BBMedicaidGA
546478200CMedicaidGA

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20101005000004 GA Practitioner - Nephrology 9830381284 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Nephrology
Education
Clvlnd Clinic Lerner College of Med of Case WSTN RSV University, 2004
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Georgia Nephrology, LLCGroup PAC ID 4082606496, 29 clinicians

Practice addresses (Care Compare)

595 Hurricane Shoals Rd NW
Suite 100
Lawrenceville, GA 30046-8762
Phone (404) 645-7150

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

Practice roles

OrganizationSpecialtyStatusNew patients
Georgia Nephrology, LLC Nephrology CurrentSince Jun 6, 2022 Accepting new patients
Macon Southside Dialysis Center LLC PastSince Sep 4, 2014 Accepting new patients

Locations

497 Winn Way
Ste A210
Decatur, GA 30030
Phone (404) 294-7033

6335 Hospital Pkwy
Ste 208
Johns Creek, GA 30097
Phone (404) 645-7150

1705 Belle Meade Ct
Ste 110
Lawrenceville, GA 30043
Phone (770) 513-2833

595 Hurricane Shoals Rd NW
Ste 100
Lawrenceville, GA 30046
Phone (404) 645-7150

Interoperability endpoints

  • Direct secure messaging: kblackwood40065@direct.acumenmd.com
  • Direct secure messaging: kimathi.blackwood@oconeeregional.gadirect.net

Organizations & group practices 2

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 9

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

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

{
    "created_epoch": "1182297600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1655769600000",
    "number": "1609071448",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "595 HURRICANE SHOALS RD NW STE 100",
            "city": "LAWRENCEVILLE",
            "state": "GA",
            "postal_code": "300468762",
            "telephone_number": "404-645-7150",
            "fax_number": "770-995-0776"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "890 SECOND STREET",
            "address_2": "SUITE 201",
            "city": "MACON",
            "state": "GA",
            "postal_code": "312016863",
            "telephone_number": "478-745-4322",
            "fax_number": "478-750-8789"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BLACKWOOD",
        "first_name": "KIMATHI",
        "middle_name": "SIPHO RICARDO",
        "name_prefix": "Dr.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2007-06-20",
        "last_updated": "2022-06-21",
        "certification_date": "2022-06-21",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207RN0300X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Nephrology",
            "state": "GA",
            "license": "063834",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "546478200BB",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "546478200C",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Macon, GA

Sources for this page

Verify at the official NPI Registry.