Basic Information
| Provider Information | |||||||||
| NPI: | 1417910902 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIALYSIS SERVICES OF NJ INC-MANAHAWKIN | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | U S RENAL CARE MANAHAWKIN DIALYSIS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19119 | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724036601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709315400 | ||||||||
| FaxNumber: | 8709315418 | ||||||||
| Practice Location | |||||||||
| Address1: | 675 ROUTE 72 E | ||||||||
| Address2: | SUITE 1006-B | ||||||||
| City: | MANAHAWKIN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080503501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6099786723 | ||||||||
| FaxNumber: | 6099786730 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2006 | ||||||||
| LastUpdateDate: | 06/21/2018 | ||||||||
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| AuthorizedOfficialLastName: | WEINBERG | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT & SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 2147362700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | U S RENAL CARE INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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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 |
ID Information
| ID | Type | State | Issuer | Description | 0000474000 | 01 | NJ | AMERIHEALTH NJ | OTHER | 60001769 | 01 | NJ | KEYSTONE MERCY | OTHER | 7078046 | 01 | NJ | AETNA | OTHER | 7881801 | 01 | NJ | AMERICHOICE | OTHER | 953402799 | 01 | NJ | AETNA MEDICARE HMO | OTHER | 2206019 | 01 | NJ | AETNA US HEALTHCARE | OTHER | 7881801 | 05 | NJ | MEDICAID | 7278046 | 01 | NJ | AETNA | OTHER | A2019304 | 01 | NJ | OXFORD HEALTH | OTHER |