Provider Demographics
NPI:1497079586
Name:RENALSOUTH OF ROGERS, LLC
Entity Type:Organization
Organization Name:RENALSOUTH OF ROGERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:CHARLOTTE
Authorized Official - Middle Name:P
Authorized Official - Last Name:ANTHONY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-271-2129
Mailing Address - Street 1:117 GEMINI CIR
Mailing Address - Street 2:SUITE 418
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35209-5874
Mailing Address - Country:US
Mailing Address - Phone:205-271-2129
Mailing Address - Fax:
Practice Address - Street 1:101 N 37TH ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-0301
Practice Address - Country:US
Practice Address - Phone:205-271-2129
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RENALSOUTH OF ARKANSAS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-03-18
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR12D01OtherBCBS
AR190358134Medicaid
AR042586Medicare Oscar/Certification