1023071222 NPI number — DVA HEALTHCARE RENAL CARE INC

Table of content: (NPI 1023071222)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023071222 NPI number — DVA HEALTHCARE RENAL CARE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DVA HEALTHCARE RENAL CARE INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
WEST PHILADELPHIA DIALYSIS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023071222
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5200 VIRGINIA WAY
Provider Second Line Business Mailing Address:
L&C DEPT
Provider Business Mailing Address City Name:
BRENTWOOD
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37027-7569
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-341-6410
Provider Business Mailing Address Fax Number:
888-662-8259

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7609 LINDBERGH BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19153-2301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-937-1103
Provider Business Practice Location Address Fax Number:
215-937-0770
Provider Enumeration Date:
04/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WEY
Authorized Official First Name:
SAMUEL
Authorized Official Middle Name:
T
Authorized Official Title or Position:
SR DIR LICENSURE & CERTIFICATION
Authorized Official Telephone Number:
615-341-6641

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 010024625 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1007635580130 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8452903 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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