Provider Demographics
NPI:1265491492
Name:RENAL TREATMENT CENTERS MID ATLANTIC INC
Entity Type:Organization
Organization Name:RENAL TREATMENT CENTERS MID ATLANTIC INC
Other - Org Name:NORTH GEORGIA DIALYSIS HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GROUP VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:O
Authorized Official - Last Name:USILTON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:770-541-7922
Mailing Address - Street 1:5200 VIRGINIA WAY
Mailing Address - Street 2:SUITE 400 L&C
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7569
Mailing Address - Country:US
Mailing Address - Phone:615-324-1638
Mailing Address - Fax:303-209-7942
Practice Address - Street 1:11685 ALPHARETTA HWY
Practice Address - Street 2:# 100
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-4913
Practice Address - Country:US
Practice Address - Phone:678-393-8144
Practice Address - Fax:678-393-8787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-17
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAESRD001056261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
112662Medicare Oscar/Certification