Basic Information
| Provider Information | |||||||||
| NPI: | 1023065554 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRODIGY DIALYSIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 FRANKLIN ST | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | JOHNSTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 159054330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8145390798 | ||||||||
| FaxNumber: | 8145364751 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 FRANKLIN ST | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | JOHNSTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 159054330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8145390798 | ||||||||
| FaxNumber: | 8145364751 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | FREM | ||||||||
| AuthorizedOfficialFirstName: | GEORGE | ||||||||
| AuthorizedOfficialMiddleName: | JOSEPH | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO & PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8142489269 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
No ID Information.