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General NPI Number Information
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NPI Number | 1376593319
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Entity Type | Organization
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Legal Business Name | SOUTHERN RENAL GROUP, INC.
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Dates
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Enumeration Date | 05/11/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2695 BUFORD HWY NE SUITE 108
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City | ATLANTA
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State | GA
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Zip | 30324-3278
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Country | US
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Telephone | 404-315-0605
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Fax | 404-315-0607
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Provider Business Mailing Address
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Address Line | 2695 BUFORD HWY NE SUITE 108
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City | ATLANTA
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State | GA
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Zip | 30324-3278
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Country | US
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Telephone | 404-315-0605
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Fax | 404-315-0607
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. BENEDICT EHIRIM
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Credential |
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Telephone | 404-315-0605
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QE0700X
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Taxonomy Name | End-Stage Renal Disease (ESRD) Treatment Clinic/Center
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License Number | 001254
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License Number State | GA
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