1689870594 NPI number — MACOMB REGIONAL DIALYSIS CENTERS, L.L.C.

Table of content: (NPI 1689870594)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689870594 NPI number — MACOMB REGIONAL DIALYSIS CENTERS, L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MACOMB REGIONAL DIALYSIS CENTERS, L.L.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MACOMB REGIONAL DIALYSIS CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689870594
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30100 TELEGRAPH ROAD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
BINGHAM FARMS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48025-4516
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-642-5038
Provider Business Mailing Address Fax Number:
248-642-7140

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16151 NINTEEN MILE RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
CLINTON TOWNSHIP
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48038-1158
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-263-8350
Provider Business Practice Location Address Fax Number:
586-263-8358
Provider Enumeration Date:
06/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SHEPHERD
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
FREDERICK
Authorized Official Title or Position:
VICE PRESIDENT / MANAGING AGENT
Authorized Official Telephone Number:
248-642-5038

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: S09456 . This is a "BLUE CROSS TRADITIONAL AND TRUST SUPPLEMENTAL" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: D8792 . This is a "BLUE CROSS TRADITIONAL AND TRUST" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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