Healthcare Provider Details

I. General information

NPI: 1740789536
Provider Name (Legal Business Name): PLOVER DIALYSIS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2018
Last Update Date: 06/17/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13945 WYOMING ST
DETROIT MI
48238-2333
US

IV. Provider business mailing address

5200 VIRGINIA WAY L&C DEPT
BRENTWOOD TN
37027
US

V. Phone/Fax

Practice location:
  • Phone: 313-931-2954
  • Fax: 313-931-3084
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SAMUEL T. WEY
Title or Position: VP LICENSURE & CERTIFICATION
Credential:
Phone: 615-341-6641