Provider Demographics
NPI:1376593319
Name:SOUTHERN RENAL GROUP, INC.
Entity Type:Organization
Organization Name:SOUTHERN RENAL GROUP, INC.
Other - Org Name:LINDBERGH DIALYSIS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BENEDICT
Authorized Official - Middle Name:
Authorized Official - Last Name:EHIRIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-315-0605
Mailing Address - Street 1:2695 BUFORD HWY NE
Mailing Address - Street 2:SUITE 108
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30324-3278
Mailing Address - Country:US
Mailing Address - Phone:404-315-0605
Mailing Address - Fax:404-315-0607
Practice Address - Street 1:2695 BUFORD HWY NE
Practice Address - Street 2:SUITE 108
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30324-3278
Practice Address - Country:US
Practice Address - Phone:404-315-0605
Practice Address - Fax:404-315-0607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001254261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11-2756Medicare ID - Type UnspecifiedDIALYSIS SERVICES