SRS-Provo, LLC

Primary specialty

End-Stage Renal Disease (ESRD) Treatment Clinic/CenterTaxonomy code 261QE0700X

Legal business name

SRS-PROVO, LLC

Practice address

1675 N Freedom Blvd
Provo, UT 84604-2540

Phone

(888) 881-7854

Fax

(885) 631-0206

NPI assigned

May 20, 2021

Last updated

May 21, 2021By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Jerome Tannenbaum, MDNPI 1346485638

Title

Ceo and Chairman of the Board

Phone

(615) 467-0140

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in UT

Enrollment records 1

Listed as

462504 SRS-Provo, LLCCCN 462504

Overall star rating

1.0 of 5

Ownership

Non-profit

Certified

Mar 25, 1977

Medicare certification status

ActiveFrom the Provider of Services file

Dialysis stations

14

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Jerome Seymour Tannenbaum, M.D., PH.D.

  • Nephrology Physician
  • Nashville, TN
  • NPI 1346485638
  NPD (past) Authorized official

Affiliated clinicians 2

Clinicians who list this facility as an affiliation in Medicare Care Compare.

• Vishnupriyadevi Parvathareddy, MD

  • Nephrology Physician
  • Murray, UT
  • NPI 1073530549

  Dialysis facility

  Care Compare affiliation Name & address match
• Robert Brown Woolley, MD

  • Nephrology Physician
  • Provo, UT
  • NPI 1104995109

  Dialysis facility

  Care Compare affiliation Name & address match

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1621468800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1621555200000",
    "number": "1679147904",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 198813",
            "city": "NASHVILLE",
            "state": "TN",
            "postal_code": "372198813",
            "telephone_number": "615-988-1060",
            "fax_number": "855-631-0206"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1675 N FREEDOM BLVD",
            "city": "PROVO",
            "state": "UT",
            "postal_code": "846042540",
            "telephone_number": "888-881-7854",
            "fax_number": "885-631-0206"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SRS-PROVO, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-05-20",
        "last_updated": "2021-05-21",
        "certification_date": "2021-05-21",
        "status": "A",
        "authorized_official_last_name": "TANNENBAUM",
        "authorized_official_first_name": "JEROME",
        "authorized_official_title_or_position": "CEO AND CHAIRMAN OF THE BOARD",
        "authorized_official_telephone_number": "615-467-0140",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QE0700X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, End-Stage Renal Disease (ESRD) Treatment",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Elizabeth Ann Spresser
• Elizabeth Renee Springfield
• Squire Counseling
• Squire Counseling
• Jasmeen Sran
• Shawna Marie St. Clair
• John K Staheli, MD
• Kendra Staheli, DNP, PMHNP-BC
• Monica Staheli
• Zachary Kenneth Staley

• End-Stage Renal Disease (ESRD) Treatment Clinic/Center in Provo, UT
• Providers in Provo, UT by specialty
• End-Stage Renal Disease (ESRD) Treatment Clinic/Center in Utah

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 21, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.