MEDICARE: SOUTHERN RENAL GROUP, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center	001254	GA

General Provider Information

NPI Number	:	1376593319
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN RENAL GROUP, INC.

Provider Business Mailing Address
First Line	:	2695 BUFORD HWY NE
Second Line	:	SUITE 108
City	:	ATLANTA
State	:	GA
Zip	:	30324-3278
Country	:	US
Telephone Number	:	404-315-0605
Fax Number	:	404-315-0607

Provider Business Practice Location Address
First Line	:	2695 BUFORD HWY NE
Second Line	:	SUITE 108
City	:	ATLANTA
State	:	GA
Zip	:	30324-3278
Country	:	US
Telephone Number	:	404-315-0605
Fax Number	:	404-315-0607

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. BENEDICT EHIRIM
Credential	:
Telephone Number	:	404-315-0605

Provider Enumeration Date	:	05/11/2006
Last Update Date	:	08/22/2020

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