Provider Demographics
NPI:1033219035
Name:DIALYSIS MANAGEMENT GROUP LLC
Entity Type:Organization
Organization Name:DIALYSIS MANAGEMENT GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:C
Authorized Official - Last Name:RAYMOND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:605-718-0391
Mailing Address - Street 1:101 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PORCUPINE
Mailing Address - State:SD
Mailing Address - Zip Code:57772
Mailing Address - Country:US
Mailing Address - Phone:605-718-0391
Mailing Address - Fax:
Practice Address - Street 1:101 MAIN STREET
Practice Address - Street 2:
Practice Address - City:PORCUPINE
Practice Address - State:SD
Practice Address - Zip Code:57772
Practice Address - Country:US
Practice Address - Phone:605-718-0391
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2009-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5400390Medicaid
SD5400390Medicaid
TX432509Medicare Oscar/Certification