Provider Demographics
NPI:1184792038
Name:DIVERSIFIED RENAL GROUP LLC
Entity type:Organization
Organization Name:DIVERSIFIED RENAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-899-3340
Mailing Address - Street 1:PO BOX 2057
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39158
Mailing Address - Country:US
Mailing Address - Phone:601-899-3340
Mailing Address - Fax:601-899-3343
Practice Address - Street 1:5903 RIDGEWOOD RD
Practice Address - Street 2:STE 340
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211
Practice Address - Country:US
Practice Address - Phone:601-899-3340
Practice Address - Fax:601-899-3343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014813Medicaid
MSC02385Medicare PIN