1518242015 NPI number — PHYSICIANS CHOICE DIALYSIS OF BRISTOW LLC

Table of content: (NPI 1518242015)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518242015 NPI number — PHYSICIANS CHOICE DIALYSIS OF BRISTOW LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICIANS CHOICE DIALYSIS OF BRISTOW LLC
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:
Provider Other Organization Name Type Code:
6
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:
1518242015
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/06/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
211 COMMERCE CT
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
POTTSTOWN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19464-3483
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-495-8900
Provider Business Mailing Address Fax Number:
610-495-8560

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
402 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRISTOW
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74010-3204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-495-8900
Provider Business Practice Location Address Fax Number:
610-495-8560
Provider Enumeration Date:
10/15/2011

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
KELLY
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF LEGAL
Authorized Official Telephone Number:
610-495-8900

Provider Taxonomy Codes

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

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

  • Identifier: 200486820A , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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