MEDICARE: BROOKHAVEN RENAL SYSTEMS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center

General Provider Information

NPI Number	:	1811338114
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROOKHAVEN RENAL SYSTEMS, LLC

Provider Business Mailing Address
First Line	:	1354 CLEVELAND AVE
Second Line	:
City	:	EAST POINT
State	:	GA
Zip	:	30344-3431
Country	:	US
Telephone Number	:	404-454-2519
Fax Number	:

Provider Business Practice Location Address
First Line	:	2695 BUFORD HWY NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30324-3278
Country	:	US
Telephone Number	:	404-454-2519
Fax Number	:

Authorized Official
Title or Position	:	CHIEF OPERATING OFFICER
Name	:	DR. MICHAEL A AKINTADE
Credential	:	R.N
Telephone Number	:	404-454-2519

Provider Enumeration Date	:	07/15/2013
Last Update Date	:	01/24/2014

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