Provider Demographics
NPI:1073590923
Name:PINE BLUFF DIALYSIS INC
Entity Type:Organization
Organization Name:PINE BLUFF DIALYSIS INC
Other - Org Name:PINE BLUFF - US RENAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHAIRMAN
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:WEINBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-736-2730
Mailing Address - Street 1:PO BOX 251549
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75025-1500
Mailing Address - Country:US
Mailing Address - Phone:870-931-5400
Mailing Address - Fax:870-931-5418
Practice Address - Street 1:2800 W 28TH AVE
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-4921
Practice Address - Country:US
Practice Address - Phone:870-534-7400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:US RENAL CARE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-12-30
Last Update Date:2022-07-21
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
AR145245734Medicaid
AR12564OtherBLUE CROSS BLUE SHIELD
042564Medicare Oscar/Certification