1265491492 NPI number — RENAL TREATMENT CENTERS MID ATLANTIC INC

Table of content: (NPI 1265491492)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265491492 NPI number — RENAL TREATMENT CENTERS MID ATLANTIC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RENAL TREATMENT CENTERS MID ATLANTIC 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:
Provider Other Organization Name Type Code:
6
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:
1265491492
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/05/2007
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:
SUITE 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:
615-324-1638
Provider Business Mailing Address Fax Number:
303-209-7942

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11685 ALPHARETTA HWY
Provider Second Line Business Practice Location Address:
# 100
Provider Business Practice Location Address City Name:
ROSWELL
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30076-4913
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-393-8144
Provider Business Practice Location Address Fax Number:
678-393-8787
Provider Enumeration Date:
03/17/2006

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:  ESRD001056 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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