Provider Demographics
NPI:1780062802
Name:RENAL TREATMENT CENTERS-ILLINOIS INC
Entity type:Organization
Organization Name:RENAL TREATMENT CENTERS-ILLINOIS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP LICENSURE & CERTIFICATION
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:WEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-341-6641
Mailing Address - Street 1:ATT: 5200 VIRGINIA WAY
Mailing Address - Street 2:ATT: L&C DEPARTMENT
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7569
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27150 PROVIDENCE PKWY
Practice Address - Street 2:STE A
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48374-1272
Practice Address - Country:US
Practice Address - Phone:248-449-6947
Practice Address - Fax:248-449-6995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-08
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1073574596Medicaid
MI1073574596Medicaid