Provider Demographics
NPI:1104891159
Name:DIALYSIS AND NEPHROLOGY CONSULTANTS PC
Entity type:Organization
Organization Name:DIALYSIS AND NEPHROLOGY CONSULTANTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-368-0824
Mailing Address - Street 1:47718 VAN DYKE AVE
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48317-3302
Mailing Address - Country:US
Mailing Address - Phone:586-446-8400
Mailing Address - Fax:586-446-8423
Practice Address - Street 1:648 PROGRESS ST STE 101
Practice Address - Street 2:
Practice Address - City:WEST BRANCH
Practice Address - State:MI
Practice Address - Zip Code:48661-8602
Practice Address - Country:US
Practice Address - Phone:989-345-0204
Practice Address - Fax:989-345-3727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-22
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICM040033207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0090010OtherBLUE CROSS SHIELD MI
MI3037050Medicaid
MI3037050Medicaid
MI0090010OtherBLUE CROSS SHIELD MI