Basic Information
| Provider Information | |||||||||
| NPI: | 1881716785 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ELLICOTT CITY DIALYSIS CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3419 PLUM TREE DR | ||||||||
| Address2: | SUITES 103-106 | ||||||||
| City: | ELLICOTT CITY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210423805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107508426 | ||||||||
| FaxNumber: | 4107508428 | ||||||||
| Practice Location | |||||||||
| Address1: | 3419 PLUM TREE DR | ||||||||
| Address2: | SUITES 103-106 | ||||||||
| City: | ELLICOTT CITY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210423805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107508426 | ||||||||
| FaxNumber: | 4107508428 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2007 | ||||||||
| LastUpdateDate: | 03/22/2019 | ||||||||
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| AuthorizedOfficialLastName: | BOUCHER | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9789223080 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| 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 | 412495200 | 05 | MD | MEDICAID |