=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104891159
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIALYSIS AND NEPHROLOGY CONSULTANTS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2006
-----------------------------------------------------
Last Update Date | 11/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 648 PROGRESS ST STE 101
-----------------------------------------------------
City | WEST BRANCH
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48661-8602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-345-0204
-----------------------------------------------------
Fax | 989-345-3727
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 47718 VAN DYKE AVE
-----------------------------------------------------
City | SHELBY TOWNSHIP
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48317-3302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-446-8400
-----------------------------------------------------
Fax | 586-446-8423
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. AMANDA GOMES
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 314-368-0824
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number | CM040033
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------