Healthcare Provider Details

I. General information

NPI: 1215393616
Provider Name (Legal Business Name): RENAL TREATMENT CENTERS - MID-ATLANTIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2016
Last Update Date: 01/10/2024
Certification Date: 01/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

829 S MAIN ST
GRAHAM NC
27253-3763
US

IV. Provider business mailing address

5200 VIRGINIA WAY L&C DEPT
BRENTWOOD TN
37027-7569
US

V. Phone/Fax

Practice location:
  • Phone: 336-229-9169
  • Fax: 336-229-6378
Mailing address:
  • Phone: 615-320-4593
  • Fax: 800-293-5872

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1215393616
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

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