Healthcare Provider Details

I. General information

NPI: 1407863194
Provider Name (Legal Business Name): DELTA RENAL GROUP, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20755 GREENFIELD RD SUITE NUMBER 203
SOUTHFIELD MI
48075-5403
US

IV. Provider business mailing address

20755 GREENFIELD RD SUITE NUMBER 203
SOUTHFIELD MI
48075-5403
US

V. Phone/Fax

Practice location:
  • Phone: 248-395-2206
  • Fax: 248-395-0456
Mailing address:
  • Phone: 248-395-2206
  • Fax: 248-395-0456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number4301072901
License Number StateMI

VIII. Authorized Official

Name: DR. BONIFACE ATAKEKOR TUBIE
Title or Position: PRESIDENT/ COE
Credential: M.D.
Phone: 248-395-2206