Provider Demographics
NPI:1114922416
Name:NORTH CENTRAL PENNSYLVANIA DIALYSIS CLINICS LLC
Entity Type:Organization
Organization Name:NORTH CENTRAL PENNSYLVANIA DIALYSIS CLINICS LLC
Other - Org Name:WILLIAMSPORT DIALYSIS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CHESTER
Authorized Official - Middle Name:A
Authorized Official - Last Name:AMEDIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-781-6212
Mailing Address - Street 1:1660 SYCAMORE RD
Mailing Address - Street 2:
Mailing Address - City:MONTOURSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17754-9314
Mailing Address - Country:US
Mailing Address - Phone:570-329-3300
Mailing Address - Fax:570-329-1069
Practice Address - Street 1:1660 SYCAMORE RD
Practice Address - Street 2:
Practice Address - City:MONTOURSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17754-9314
Practice Address - Country:US
Practice Address - Phone:570-329-3300
Practice Address - Fax:570-329-1069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-15
Last Update Date:2020-08-22
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
PA1837223Medicaid
PA392684Medicare ID - Type Unspecified