Basic Information
| Provider Information | |||||||||
| NPI: | 1447495916 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CREEK DIALYSIS LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CALVERTON DIALYSIS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5200 VIRGINIA WAY | ||||||||
| Address2: | L&C DEPT | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370277569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153204214 | ||||||||
| FaxNumber: | 8669443352 | ||||||||
| Practice Location | |||||||||
| Address1: | 4780 CORRIDOR PL | ||||||||
| Address2: | STE C | ||||||||
| City: | BELTSVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207051165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3015950231 | ||||||||
| FaxNumber: | 3015953439 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2008 | ||||||||
| LastUpdateDate: | 04/28/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WINSTEL | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF ACCOUNTING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2537334501 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | E2663 | MD | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 4325028 00 | 05 | MD | MEDICAID |