Basic Information
| Provider Information | |||||||||
| NPI: | 1689940116 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIALYSIS NEWCO INC | ||||||||
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| OtherOrganizationName: | DSI WATERVILET DIALYSIS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 424 CHURCH ST | ||||||||
| Address2: | SUITE 1900 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372192301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6157778201 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8816 RED ARROW HWY | ||||||||
| Address2: | |||||||||
| City: | WATERVLIET | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490988536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694633719 | ||||||||
| FaxNumber: | 2694633901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2012 | ||||||||
| LastUpdateDate: | 03/29/2012 | ||||||||
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| AuthorizedOfficialLastName: | BAKER | ||||||||
| AuthorizedOfficialFirstName: | TAMMY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGED CARE COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 6152341188 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | MI | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
No ID Information.