Provider Demographics
NPI:1649556721
Name:DRG FAYETTE, PLLC
Entity Type:Organization
Organization Name:DRG FAYETTE, PLLC
Other - Org Name:DIVERSIFIED RENAL GROUP HOME DIALYSIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TUNDE
Authorized Official - Middle Name:
Authorized Official - Last Name:OLUTADE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-899-3340
Mailing Address - Street 1:5903 RIDGEWOOD RD
Mailing Address - Street 2:SUITE 340
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-3700
Mailing Address - Country:US
Mailing Address - Phone:601-488-1070
Mailing Address - Fax:
Practice Address - Street 1:1005 MAIN STREET
Practice Address - Street 2:
Practice Address - City:FAYETTE
Practice Address - State:MS
Practice Address - Zip Code:39069
Practice Address - Country:US
Practice Address - Phone:601-488-1070
Practice Address - Fax:601-899-3343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-02
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment