Provider Demographics
NPI:1295799641
Name:CSRA RENAL SERVICES, LLC
Entity type:Organization
Organization Name:CSRA RENAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:STAHURA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:803-648-0718
Mailing Address - Street 1:755 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29801-6306
Mailing Address - Country:US
Mailing Address - Phone:803-648-0718
Mailing Address - Fax:803-641-9143
Practice Address - Street 1:755 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-6306
Practice Address - Country:US
Practice Address - Phone:803-648-0718
Practice Address - Fax:803-641-9143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-13
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3601Medicaid
SC7953457OtherAETNA GROUP NUMBER
SCGP4396Medicaid
SCGP3601Medicaid
SCGP4396Medicaid
SC7953457OtherAETNA GROUP NUMBER
SC7503Medicare ID - Type UnspecifiedGROUP PROVIDER NUMBER