1669480422 NPI number — INDEPENDENT DIALYSIS FOUNDATION, INC

Table of content: (NPI 1669480422)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669480422 NPI number — INDEPENDENT DIALYSIS FOUNDATION, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDEPENDENT DIALYSIS FOUNDATION, 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:
Provider Other Organization Name Type Code:
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:
1669480422
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/16/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
840 HOLLINS ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21201-1024
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-468-0900
Provider Business Mailing Address Fax Number:
410-468-0911

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
225 W DARES BEACH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRINCE FREDERICK
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20678-3123
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-468-0900
Provider Business Practice Location Address Fax Number:
410-468-0911
Provider Enumeration Date:
08/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
AYELE
Authorized Official First Name:
ZEKE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF INFORMATION SYSTEMS
Authorized Official Telephone Number:
410-468-0900

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X , with the licence number:  E2549R , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PS6 . This is a "FEP" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 0005759000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01689292 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 590079-01 . This is a "CAREFIRST" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 0125608 . This is a "AETNA" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 21506 . This is a "JAI MEDICAL" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 215143 . This is a "MDIPA" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 0704865003 . This is a "CIGNA" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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