1568559128 NPI number — COMMUNITY DIALYSIS CENTER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568559128 NPI number — COMMUNITY DIALYSIS CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMUNITY DIALYSIS CENTER
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:
CENTER FOR DIALYSIS CARE, CLEVELAND WEST
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:
1568559128
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/10/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18720 CHAGRIN BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHAKER HEIGHTS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44122-4855
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-295-7003
Provider Business Mailing Address Fax Number:
216-295-7014

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3330 W 25TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44109-1614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-741-5776
Provider Business Practice Location Address Fax Number:
216-741-5467
Provider Enumeration Date:
10/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WISH
Authorized Official First Name:
DIANE
Authorized Official Middle Name:
P
Authorized Official Title or Position:
PRES AND CEO
Authorized Official Telephone Number:
216-295-7003

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X , with the licence number:  0368DC , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3127262 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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