Basic Information
| Provider Information | |||||||||
| NPI: | 1902837123 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GULF COAST KIDNEY CENTER INC | ||||||||
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| OtherOrganizationName: | PHYSICIANS DIALYSIS HUDSON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19559 N E 10 AVENUE | ||||||||
| Address2: | |||||||||
| City: | N MIAMI BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331793501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056513261 | ||||||||
| FaxNumber: | 3056512961 | ||||||||
| Practice Location | |||||||||
| Address1: | 14153 YOSEMITE DR | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | HUDSON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346678060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278620603 | ||||||||
| FaxNumber: | 7278624939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 05/03/2010 | ||||||||
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| AuthorizedOfficialLastName: | FERNANDEZ | ||||||||
| AuthorizedOfficialFirstName: | ARTURO | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3056513261 | ||||||||
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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 | 209147001 | 05 | FL | MEDICAID |