Provider Demographics
NPI:1316967797
Name:SOUTHEASTERN MICHIGAN KIDNEY CENTER PLLC
Entity type:Organization
Organization Name:SOUTHEASTERN MICHIGAN KIDNEY CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:F
Authorized Official - Last Name:SHEPHERD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-642-5038
Mailing Address - Street 1:30100 TELEGRAPH RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BINGHAM FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-4516
Mailing Address - Country:US
Mailing Address - Phone:248-723-0224
Mailing Address - Fax:248-642-7852
Practice Address - Street 1:1695 W 12 MILE RD
Practice Address - Street 2:SUITE 250
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-2183
Practice Address - Country:US
Practice Address - Phone:248-414-5200
Practice Address - Fax:248-414-5227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2011-09-28
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
000000009371OtherCAPE
08981OtherBLUE CROSS PRIMARY
08981OtherFED BLUE CROSS PRIMARY
1022510001OtherWELLNESS
140042OtherCARE CHOICES
OP630345OtherM CARE
09499OtherBLUE CROSS SECONDARY
501076OtherULTI MED
567595OtherSELECTCARE
P117519OtherBLUE CARE NETWORK
140042OtherPREFERRED CHOICE
09499OtherFED BLUE CROSS SECONDARY
8203OtherGREATLAKES
232574OtherHAP
MI4112097Medicaid
MI4112097Medicaid