Basic Information
Provider Information | |||||||||
NPI: | 1306880075 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | REGIONAL DIALYSIS SERVICES INC | ||||||||
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: | 9894663395 | ||||||||
FaxNumber: | 9894667454 | ||||||||
Practice Location | |||||||||
Address1: | 3170 S. PROFESSIONAL DRIVE | ||||||||
Address2: |   | ||||||||
City: | BAY CITY | ||||||||
State: | MI | ||||||||
PostalCode: | 48706 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9896868782 | ||||||||
FaxNumber: | 9896868563 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/15/2006 | ||||||||
LastUpdateDate: | 03/08/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CURRIE | ||||||||
AuthorizedOfficialFirstName: | SCOTT | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
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 | 40-3021514 | 05 | MI |   | MEDICAID | 09428 | 01 | MI | BCBSM | OTHER | 08937 | 01 | MI | BCBSM | OTHER |