Basic Information
| Provider Information | |||||||||
| NPI: | 1114973583 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ISD RENAL INC | ||||||||
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| OtherOrganizationName: | BUTLER RENAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5200 VIRGINIA WAY | ||||||||
| Address2: | L&C DEPT | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370277569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153415893 | ||||||||
| FaxNumber: | 8778507073 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 W NURSERY ST | ||||||||
| Address2: | |||||||||
| City: | BUTLER | ||||||||
| State: | MO | ||||||||
| PostalCode: | 647301872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6606796513 | ||||||||
| FaxNumber: | 6606796517 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 10/26/2015 | ||||||||
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| AuthorizedOfficialLastName: | HILGERR | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF ACCOUNTING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2537334500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 | 505342501 | 05 | MO | MEDICAID | 200548640C | 05 | KS | MEDICAID |