Basic Information
| Provider Information | |||||||||
| NPI: | 1447228648 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DVA RENAL HEALTHCARE INC | ||||||||
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| OtherOrganizationName: | FULTON DIALYSIS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5200 VIRGINIA WAY | ||||||||
| Address2: | SUITE 400 L&C DEPT | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370277569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153204218 | ||||||||
| FaxNumber: | 3032097825 | ||||||||
| Practice Location | |||||||||
| Address1: | 993 JOHNSON FERRY RD NE | ||||||||
| Address2: | BLDG D STE 130 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042563118 | ||||||||
| FaxNumber: | 4048430689 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 08/15/2007 | ||||||||
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| AuthorizedOfficialLastName: | USILTON | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | O | ||||||||
| AuthorizedOfficialTitleorPosition: | GROUP VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7705417922 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | ESRD001031 | GA | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | OH=2509940 | 05 | OH | MEDICAID |