1922311612 NPI number — DIALYSIS PARTNERS OF NORTHWEST OHIO, LLC

Table of content: (NPI 1922311612)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922311612 NPI number — DIALYSIS PARTNERS OF NORTHWEST OHIO, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIALYSIS PARTNERS OF NORTHWEST OHIO, 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:
1922311612
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30100 TELEGRAPH RD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
BINGHAM FARMS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48025-4516
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-723-0224
Provider Business Mailing Address Fax Number:
248-642-7852

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5308 HARROUN RD
Provider Second Line Business Practice Location Address:
SUITE 60
Provider Business Practice Location Address City Name:
SYLVANIA
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43560-2114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-642-5038
Provider Business Practice Location Address Fax Number:
248-642-7852
Provider Enumeration Date:
07/22/2010

Additional Information

Authorized Official

Authorized Official Last Name:
SHEPHERD
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
F
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
248-642-5038

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X , with the licence number:  1036435 , 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: 0062708 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000327208 . This is a "ANTHEM BC" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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