Provider Demographics
NPI:1144301243
Name:HOME DIALYSIS OF NORTH ALABAMA INC.
Entity type:Organization
Organization Name:HOME DIALYSIS OF NORTH ALABAMA INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:REGINALD
Authorized Official - Middle Name:DWAIN
Authorized Official - Last Name:GLADISH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-340-0012
Mailing Address - Street 1:1216 SOMERVILLE ROAD S.E.
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601
Mailing Address - Country:US
Mailing Address - Phone:256-340-0012
Mailing Address - Fax:256-340-1408
Practice Address - Street 1:1216 SOMERVILLE RD SE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-4335
Practice Address - Country:US
Practice Address - Phone:256-340-0012
Practice Address - Fax:256-340-1408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL012620Medicare ID - Type Unspecified