DRG Fayette PLLC
Organization Active NPI End-Stage Renal Disease (ESRD) Treatment Clinic/Center · Fayette, MS
NPI 1891978953 · NPPES record last updated Jan 15, 2008
Key facts
- NPI
- 1891978953
- Entity type
- Organization (NPI type 2)
- Primary specialty
- End-Stage Renal Disease (ESRD) Treatment Clinic/Center 261QE0700X
- Legal business name
- DRG FAYETTE PLLC
- Practice address
- 225 Community Drive
Off Hwy 61
Fayette, MS 39069 - Phone
- (601) 786-6676
- Fax
- (601) 786-6678
- NPI assigned
- Dec 12, 2007
- Organization subpart
- No
Authorized official
- Name
- Tunde Olutade
- Title
- Member
- Phone
- (601) 899-3340
Other NPIs with the same Medicare PAC ID 1
Corporate family (same tax ID) 1
Practitioners 1
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MS
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20071231000076 | MS | Part a Provider - End-Stage Renal Disease Facility (ESRD) | 8820178049 | Practice locations: Fayette, MS |
National Provider Directory
- Tax ID family
- Diversified Renal Group Fayette PLLC
Locations
225 Community Dr
Fayette, MS 39069
Phone (601) 786-2475
5903 Ridgewood Rd
Ste 340
Jackson, MS 39211
Phone (601) 899-3340
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| End-Stage Renal Disease (ESRD) Treatment Clinic/Center | 261QE0700X | MS | Yes |
Addresses
Primary practice location
225 Community Drive
Off Hwy 61
Fayette, MS 39069
Mailing address
5903 Ridgewood Rd
Suite 340
Jackson, MS 39211-3700
Phone (601) 899-3340
Other names
- Diversified Renal Group Fayette, PLLC
Other providers in Fayette, MS
- Chambliss Counseling Services PLLC
- Sharron Daneka Chambliss
- Crystal S Cook
- Tiffany Nicole Cruel
- Gabrielle Doss
- DRG Fayette, PLLC
- John Ellis Evans
- Evers Personal Care & Respite Services LLC
- Fayette Express Pharmacy
- Georgene Ferrie
All providers in Fayette, MS · End-Stage Renal Disease (ESRD) Treatment Clinic/Center in Mississippi
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jan 15, 2008. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.