1316069701 NPI number — GRAYSON DIALYSIS AND KIDNEY CENTER

Table of content: (NPI 1316069701)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316069701 NPI number — GRAYSON DIALYSIS AND KIDNEY CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRAYSON DIALYSIS AND KIDNEY CENTER
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:
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:
1316069701
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:
286 HIGHWAY 1947
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAYSON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41143
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-474-2310
Provider Business Mailing Address Fax Number:
606-474-0569

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1656 13TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUNTINGTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25701-3829
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-529-2090
Provider Business Practice Location Address Fax Number:
304-522-2658
Provider Enumeration Date:
04/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KUMAR
Authorized Official First Name:
SUBHASH
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER MEDICAL DIRECTOR
Authorized Official Telephone Number:
304-654-8074

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: 3810006539 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000494978 . This is a "ANTHEM BCBS PROV NUMBER" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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