Provider Demographics
NPI:1114035912
Name:WISCONSIN DIALYSIS, INC.
Entity Type:Organization
Organization Name:WISCONSIN DIALYSIS, INC.
Other - Org Name:EAST CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:KRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-270-5624
Mailing Address - Street 1:3034 FISH HATCHERY RD
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53713-3125
Mailing Address - Country:US
Mailing Address - Phone:608-270-5600
Mailing Address - Fax:608-270-5602
Practice Address - Street 1:4600 AMERICAN PKWY
Practice Address - Street 2:STE 108
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53718-8337
Practice Address - Country:US
Practice Address - Phone:608-243-3003
Practice Address - Fax:608-243-3005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2019-06-24
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
WI42059900Medicaid
WI42059900Medicaid