Basic Information
| Provider Information | |||||||||
| NPI: | 1053355388 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THUMB AREA DIALYSIS CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 188 | ||||||||
| Address2: | |||||||||
| City: | ALMA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488010188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9894663349 | ||||||||
| FaxNumber: | 9894667454 | ||||||||
| Practice Location | |||||||||
| Address1: | 6757 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CASS CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 487261556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898725544 | ||||||||
| FaxNumber: | 9898725692 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 12/14/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MORGAN | ||||||||
| AuthorizedOfficialFirstName: | VICTOR | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | V.P. OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 9894663272 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 40-4090623 | 05 | MI | MEDICAID | 08982 | 01 | MI | BCBSM | OTHER | 09426 | 01 | MI | BCBSM | OTHER |