Healthcare Provider Details

I. General information

NPI: 1861667891
Provider Name (Legal Business Name): COMPREHENSIVE NEPHROLOGY CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2008
Last Update Date: 04/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 BARTOW ST
THOMASVILLE GA
31792-6076
US

IV. Provider business mailing address

415 BARTOW ST P.O. BOX 3027
THOMASVILLE GA
31792-6076
US

V. Phone/Fax

Practice location:
  • Phone: 229-226-6116
  • Fax: 229-226-6128
Mailing address:
  • Phone: 229-226-6116
  • Fax: 229-226-6128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number047235
License Number StateGA

VIII. Authorized Official

Name: DR. DWIGHT A MCLEISH
Title or Position: OWNER
Credential: M.D.
Phone: 229-226-6116