Basic Information
| Provider Information | |||||||||
| NPI: | 1538265335 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AFTON NEPHROLOGY ASSOCIATES | ||||||||
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| OtherOrganizationName: | STATE FAIR DIALYSIS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19800 WOODWARD AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482035102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138938610 | ||||||||
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| Practice Location | |||||||||
| Address1: | 19800 WOODWARD AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482035102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138938610 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | DONALDSON | ||||||||
| AuthorizedOfficialFirstName: | RACHEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3138938610 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | 4301406139 | MI | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 49441 | 01 | MI | OMNICARE | OTHER | 9367 | 01 | MI | CAPE HEALTH PLAN | OTHER | D9411 | 01 | MI | BCBS | OTHER | 08999 | 01 | MI | BCN | OTHER | 08999 | 01 | MI | BCBS | OTHER | 14040 | 01 | MI | MCARE | OTHER |