Provider Demographics
NPI:1164734596
Name:RENAL CONSULTANT PC
Entity Type:Organization
Organization Name:RENAL CONSULTANT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GAMPALA
Authorized Official - Middle Name:H
Authorized Official - Last Name:REDDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-817-5264
Mailing Address - Street 1:PO BOX 251221
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48325-1221
Mailing Address - Country:US
Mailing Address - Phone:248-720-9226
Mailing Address - Fax:
Practice Address - Street 1:1380 COOLIDGE HWY STE 150
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-7058
Practice Address - Country:US
Practice Address - Phone:248-817-5264
Practice Address - Fax:248-829-7752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-14
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIGR088423207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F39037OtherBCBS
MI0F39037OtherBCBS