Provider Demographics
NPI:1932181278
Name:DIALYSIS AFFILIATES OF SOUTH ALABAMA
Entity type:Organization
Organization Name:DIALYSIS AFFILIATES OF SOUTH ALABAMA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:D
Authorized Official - Last Name:RAULERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:251-867-3650
Mailing Address - Street 1:1205 BELLEVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:BREWTON
Mailing Address - State:AL
Mailing Address - Zip Code:36426-1304
Mailing Address - Country:US
Mailing Address - Phone:251-867-3650
Mailing Address - Fax:251-867-3610
Practice Address - Street 1:1205 BELLEVILLE AVE
Practice Address - Street 2:
Practice Address - City:BREWTON
Practice Address - State:AL
Practice Address - Zip Code:36426-1304
Practice Address - Country:US
Practice Address - Phone:251-867-3650
Practice Address - Fax:251-867-3610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-14
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL10749261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALDIA2549DMedicaid
AL264DASOtherBC/BS OF ALABAMA
ALDIA2549DMedicaid