Provider Demographics
NPI:1689870594
Name:MACOMB REGIONAL DIALYSIS CENTERS, L.L.C.
Entity Type:Organization
Organization Name:MACOMB REGIONAL DIALYSIS CENTERS, L.L.C.
Other - Org Name:MACOMB REGIONAL DIALYSIS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT / MANAGING AGENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:FREDERICK
Authorized Official - Last Name:SHEPHERD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-642-5038
Mailing Address - Street 1:30100 TELEGRAPH ROAD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BINGHAM FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-4516
Mailing Address - Country:US
Mailing Address - Phone:248-642-5038
Mailing Address - Fax:248-642-7140
Practice Address - Street 1:16151 NINTEEN MILE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-1158
Practice Address - Country:US
Practice Address - Phone:586-263-8350
Practice Address - Fax:586-263-8358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2018-10-15
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
MIS09456OtherBLUE CROSS TRADITIONAL AND TRUST SUPPLEMENTAL
MID8792OtherBLUE CROSS TRADITIONAL AND TRUST
MI232642Medicare Oscar/Certification