Organization
DIVERSIFIED RENAL GROUP LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
GARY M DAVIS MD (MEMBER)
(601) 899-3340
Entity
Organization
Contact information
Practice address
5903 RIDGEWOOD RD, STE 340, JACKSON, MS 39211
(601) 899-3340
(601) 899-3343
Mailing address
PO BOX 2057, RIDGELAND, MS 39158
(601) 899-3340
(601) 899-3343
Taxonomy
Speciality
Code
Description
License number
State
207RN0300X
Nephrology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
09014813
—
MS
Enumeration date
11/30/2006
Last updated
04/25/2008
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