Provider Demographics
NPI:1902080062
Name:CHAMPION HEALTHCARE AND NEPHROLOGY, LLC
Entity Type:Organization
Organization Name:CHAMPION HEALTHCARE AND NEPHROLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ARDESAR
Authorized Official - Last Name:MORROW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-484-4842
Mailing Address - Street 1:7525 COVINGTON HWY
Mailing Address - Street 2:SUITE D
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-7439
Mailing Address - Country:US
Mailing Address - Phone:770-484-4842
Mailing Address - Fax:770-484-9595
Practice Address - Street 1:7525 COVINGTON HWY
Practice Address - Street 2:SUITE D
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-7439
Practice Address - Country:US
Practice Address - Phone:770-484-4842
Practice Address - Fax:770-484-9595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-26
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA48067207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6742Medicare PIN