Provider Demographics
NPI:1184868051
Name:PRODIGY DIALYSIS
Entity Type:Organization
Organization Name:PRODIGY DIALYSIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:J
Authorized Official - Last Name:FREM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:814-539-0798
Mailing Address - Street 1:88 OSBORNE ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-4146
Mailing Address - Country:US
Mailing Address - Phone:814-539-0798
Mailing Address - Fax:814-536-4751
Practice Address - Street 1:1100 W HIGH ST
Practice Address - Street 2:
Practice Address - City:EBENSBURG
Practice Address - State:PA
Practice Address - Zip Code:15931-1706
Practice Address - Country:US
Practice Address - Phone:814-419-8107
Practice Address - Fax:814-419-8108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-23
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD042825E261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA392754Medicare UPIN