Provider Demographics
NPI:1407863194
Name:DELTA RENAL GROUP, P.C.
Entity Type:Organization
Organization Name:DELTA RENAL GROUP, P.C.
Other - Org Name:BONIFACE TUBIE, M.D.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/ COE
Authorized Official - Prefix:DR
Authorized Official - First Name:BONIFACE
Authorized Official - Middle Name:ATAKEKOR
Authorized Official - Last Name:TUBIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-395-2206
Mailing Address - Street 1:20755 GREENFIELD RD
Mailing Address - Street 2:SUITE NUMBER 203
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-5403
Mailing Address - Country:US
Mailing Address - Phone:248-395-2206
Mailing Address - Fax:248-395-0456
Practice Address - Street 1:20755 GREENFIELD RD
Practice Address - Street 2:SUITE NUMBER 203
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-5403
Practice Address - Country:US
Practice Address - Phone:248-395-2206
Practice Address - Fax:248-395-0456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301072901207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4341231Medicaid
MI4341231Medicaid
MIG81616Medicare UPIN