Provider Demographics
NPI:1083634463
Name:NORTHWEST DETROIT DIALYSIS CENTER LLC
Entity Type:Organization
Organization Name:NORTHWEST DETROIT DIALYSIS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:F
Authorized Official - Last Name:SHEPHERD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-642-5038
Mailing Address - Street 1:30100 TELEGRAPH RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BINGHAM FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-4516
Mailing Address - Country:US
Mailing Address - Phone:248-723-0224
Mailing Address - Fax:248-642-7852
Practice Address - Street 1:25664 LAHSER RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-5810
Practice Address - Country:US
Practice Address - Phone:248-358-7521
Practice Address - Fax:248-358-7522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2012-10-15
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
14296OtherM CARE
10078540001OtherWELLNESS
1008733OtherOMNICARE
D8956OtherFED BLUE CROSS PRIMARY
232544OtherHAP
MI4568218Medicaid
000000003402OtherCAPE
138129OtherPREFERRED CHOICE
138129OtherCARE CHOICES
D8956OtherBLUE CROSS PRIMARY
D9466OtherBLUE CROSS SECONDARY
D9466OtherFED BLUE CROSS SECONDARY
P09457OtherBLUE CARE NETWORK
5066OtherGREATLAKES
138129OtherPREFERRED CHOICE