Healthcare Provider Details

I. General information

NPI: 1184792038
Provider Name (Legal Business Name): DIVERSIFIED RENAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 04/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5903 RIDGEWOOD RD STE 340
JACKSON MS
39211
US

IV. Provider business mailing address

PO BOX 2057
RIDGELAND MS
39158
US

V. Phone/Fax

Practice location:
  • Phone: 601-899-3340
  • Fax: 601-899-3343
Mailing address:
  • Phone: 601-899-3340
  • Fax: 601-899-3343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: GARY M DAVIS
Title or Position: MEMBER
Credential: MD
Phone: 601-899-3340