MEDICARE: AFTON NEPHROLOGY ASSOCIATES

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	4301406139	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	49441	OTHER	MI	OMNICARE
2	9367	OTHER	MI	CAPE HEALTH PLAN
3	D9411	OTHER	MI	BCBS
4	08999	OTHER	MI	BCN
5	08999	OTHER	MI	BCBS
6	14040	OTHER	MI	MCARE

General Provider Information

NPI Number	:	1538265335
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AFTON NEPHROLOGY ASSOCIATES

Provider Business Mailing Address
First Line	:	19800 WOODWARD AVE
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48203-5102
Country	:	US
Telephone Number	:	313-893-8610
Fax Number	:

Provider Business Practice Location Address
First Line	:	19800 WOODWARD AVE
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48203-5102
Country	:	US
Telephone Number	:	313-893-8610
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. RACHEL DONALDSON
Credential	:	M.D.
Telephone Number	:	313-893-8610

Provider Enumeration Date	:	09/16/2006
Last Update Date	:	04/20/2008

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Directions to “AFTON NEPHROLOGY ASSOCIATES ” Practice Location

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