Provider Demographics
NPI:1134198427
Name:DIALSIS TREATMENT CENTERS OF MACON LLC
Entity type:Organization
Organization Name:DIALSIS TREATMENT CENTERS OF MACON LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GROUP VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:O
Authorized Official - Last Name:USILTON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:770-541-7922
Mailing Address - Street 1:5200 VIRGINIA WAY
Mailing Address - Street 2:SUITE 400 L&C
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7569
Mailing Address - Country:US
Mailing Address - Phone:615-320-4218
Mailing Address - Fax:615-320-4487
Practice Address - Street 1:745 PINE ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2106
Practice Address - Country:US
Practice Address - Phone:478-741-9810
Practice Address - Fax:478-741-9810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAESRD001045261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
11-2654Medicare ID - Type Unspecified