Provider Demographics
NPI:1083634471
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:48025-4514
Mailing Address - Country:US
Mailing Address - Phone:248-642-5038
Mailing Address - Fax:248-642-7140
Practice Address - Street 1:7800 W OUTER DR
Practice Address - Street 2:SUITE 190
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-3461
Practice Address - Country:US
Practice Address - Phone:313-270-9239
Practice Address - Fax:313-270-9238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2015-03-04
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
000000003402OtherCAPE
1008733OtherOMNICARE
09457OtherBLUE CROSS SECONDARY
14296OtherM CARE
08954OtherFED BLUE CROSS PRIMARY
10078540001OtherWELLNESS
232544OtherHAP
138129OtherPREFERRED CHOICE
5066OtherGREATLAKES
08954OtherBLUE CROSS PRIMARY
138129OtherCARE CHOICES
09457OtherFED BLUE CROSS SECONDARY
MI3194098Medicaid
P09457OtherBLUE CARE NETWORK
5066OtherGREATLAKES