Provider Demographics
NPI:1265494470
Name:RENAL TREATMENT CENTERS ILLINOIS INC
Entity Type:Organization
Organization Name:RENAL TREATMENT CENTERS ILLINOIS INC
Other - Org Name:WEST DETROIT DIALYSIS
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:STE. 400 L&C
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7569
Mailing Address - Country:US
Mailing Address - Phone:615-320-4435
Mailing Address - Fax:303-209-7821
Practice Address - Street 1:12950 W CHICAGO ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48228-2651
Practice Address - Country:US
Practice Address - Phone:313-491-7450
Practice Address - Fax:313-491-5977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-04
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4636452Medicaid
LA1791733Medicaid
232593Medicare Oscar/Certification