Healthcare Provider Details

I. General information

NPI: 1548835879
Provider Name (Legal Business Name): SRS-PAYSON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2021
Last Update Date: 05/21/2021
Certification Date: 05/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 S 1000 E
PAYSON UT
84651-5590
US

IV. Provider business mailing address

PO BOX 198813
NASHVILLE TN
37219-8813
US

V. Phone/Fax

Practice location:
  • Phone: 888-883-6407
  • Fax: 855-631-0206
Mailing address:
  • Phone: 615-988-1060
  • Fax: 855-631-0206

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:

VIII. Authorized Official

Name: JEROME TANNENBAUM
Title or Position: CEO AND CHAIRMAN OF THE BOARD
Credential: MD
Phone: 615-467-0140