1649233222 NPI number — DVA RENAL HEALTHCARE, INC.

Table of content: MS. PHYLLIS ANN GROSSMAN M.C. (NPI 1972656296)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649233222 NPI number — DVA RENAL HEALTHCARE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DVA RENAL HEALTHCARE, INC.
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:
MCMINNVILLE DIALYSIS
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:
1649233222
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5200 VIRGINIA WAY
Provider Second Line Business Mailing Address:
STE. 400 L&C
Provider Business Mailing Address City Name:
BRENTWOOD
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37027-7569
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-320-4218
Provider Business Mailing Address Fax Number:
303-209-7825

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
835 SMITHVILLE HWY
Provider Second Line Business Practice Location Address:
#15
Provider Business Practice Location Address City Name:
MC MINNVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37110-1669
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-473-9553
Provider Business Practice Location Address Fax Number:
931-473-2676
Provider Enumeration Date:
04/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
USILTON
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
O.
Authorized Official Title or Position:
GROUP VICE PRESIDENT
Authorized Official Telephone Number:
770-541-7922

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X , with the licence number:  113 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0442558 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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