Provider Demographics
NPI:1821207911
Name:DYERSBURG KIDNEY CLINIC, INC
Entity Type:Organization
Organization Name:DYERSBURG KIDNEY CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KANDALA
Authorized Official - Middle Name:RAM
Authorized Official - Last Name:CHARY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:731-668-6907
Mailing Address - Street 1:640C HWY 51 BYPASS
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024
Mailing Address - Country:US
Mailing Address - Phone:731-668-6907
Mailing Address - Fax:
Practice Address - Street 1:16 MURRAY GUARD DRIVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305
Practice Address - Country:US
Practice Address - Phone:731-668-4284
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN281P00000X
TNMD00000124282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered281P00000XHospitalsChronic Disease Hospital
Not Answered282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNB03826Medicare UPIN