Basic Information
Provider Information | |||||||||
NPI: | 1295765071 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RENAL CENTER PHYSICIANS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 22201 MOROSS RD STE 150 | ||||||||
Address2: |   | ||||||||
City: | DETROIT | ||||||||
State: | MI | ||||||||
PostalCode: | 482362152 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5862474300 | ||||||||
FaxNumber: | 5865326496 | ||||||||
Practice Location | |||||||||
Address1: | 2607 ELECTRIC AVE STE E | ||||||||
Address2: |   | ||||||||
City: | PORT HURON | ||||||||
State: | MI | ||||||||
PostalCode: | 480606587 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8109875252 | ||||||||
FaxNumber: | 8109872120 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/04/2006 | ||||||||
LastUpdateDate: | 06/17/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MUTHUSWAMI | ||||||||
AuthorizedOfficialFirstName: | SUBBANA | ||||||||
AuthorizedOfficialMiddleName: | GOUNDER | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8109875252 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
ID | Type | State | Issuer | Description | 102570422 | 05 | MI |   | MEDICAID |