Provider Demographics
NPI:1083735567
Name:MIDWEST DIALYSIS CENTER, INC
Entity Type:Organization
Organization Name:MIDWEST DIALYSIS CENTER, INC
Other - Org Name:MIDWEST DIALYSIS CENTER, INC-27TH STREET BRANCH
Other - Org Type:Other Name
Authorized Official - Title/Position:V.P. OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:KURZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-762-2020
Mailing Address - Street 1:335 EAST MAHN COURT
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154
Mailing Address - Country:US
Mailing Address - Phone:414-762-2020
Mailing Address - Fax:414-762-2024
Practice Address - Street 1:3120 S 27TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4338
Practice Address - Country:US
Practice Address - Phone:414-672-1006
Practice Address - Fax:414-672-1016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2011-10-27
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
WI42063100OtherMEDICAID PROVIDER NUMBER
WI42063100Medicaid
WI522573OtherMEDICARE PROVIDER NUMBER
WI522573Medicare ID - Type Unspecified