Basic Information
| Provider Information | |||||||||
| NPI: | 1407384274 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ISD RENAL INC | ||||||||
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| OtherOrganizationName: | CROSS KEYS DIALYSIS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5200 VIRGINIA WAY | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370277569 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 14001 NEW HALLS FERRY RD STE 133 | ||||||||
| Address2: | |||||||||
| City: | FLORISSANT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630332708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148397416 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2017 | ||||||||
| LastUpdateDate: | 05/24/2017 | ||||||||
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| AuthorizedOfficialLastName: | HILGER | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF ACCOUNTING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2537334500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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.