1720245152 NPI number — POOLER DIALYSIS LLC

Table of content: DR. GREGG ALLEN REES DDS (NPI 1659432045)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720245152 NPI number — POOLER DIALYSIS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
POOLER DIALYSIS LLC
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:
1720245152
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2014
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:
L&C DEPARTMENT
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:
615-320-4286
Provider Business Mailing Address Fax Number:
866-594-2893

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
54 TRADERS WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POOLER
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31322-4158
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-748-1018
Provider Business Practice Location Address Fax Number:
912-748-4187
Provider Enumeration Date:
05/22/2008

Additional Information

Authorized Official

Authorized Official Last Name:
HILGER
Authorized Official First Name:
JIM
Authorized Official Middle Name:
K
Authorized Official Title or Position:
CHIEF ACCOUNTING OFFICER
Authorized Official Telephone Number:
253-733-4500

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X , with the licence number:  ESRD000772 , 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)

  • Identifier: 000619561AH , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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