Basic Information
| Provider Information | |||||||||
| NPI: | 1811338460 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BUSHWICK CENTER FOR RENAL DIALYSIS, LLC | ||||||||
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| Address1: | 50 SHEFFIELD AVE | ||||||||
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| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112072420 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 50 SHEFFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112072420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183452273 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2013 | ||||||||
| LastUpdateDate: | 01/13/2015 | ||||||||
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| AuthorizedOfficialLastName: | MEISELS | ||||||||
| AuthorizedOfficialFirstName: | JACK | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 7183452273 | ||||||||
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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 |
ID Information
| ID | Type | State | Issuer | Description | 03967668 | 05 | NY | MEDICAID |