Provider Demographics
NPI:1194230441
Name:ISD RENAL INC
Entity Type:Organization
Organization Name:ISD RENAL INC
Other - Org Name:MERCHANTVILLE DIALYSIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP, LICENSURE & CERTIFICATION
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-341-6641
Mailing Address - Street 1:5200 VIRGINIA WAY
Mailing Address - Street 2:L&C DEPT
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7569
Mailing Address - Country:US
Mailing Address - Phone:615-341-6410
Mailing Address - Fax:888-662-8259
Practice Address - Street 1:5000 N CRESCENT BLVD
Practice Address - Street 2:STE 1A
Practice Address - City:PENNSAUKEN
Practice Address - State:NJ
Practice Address - Zip Code:08109-2151
Practice Address - Country:US
Practice Address - Phone:856-910-8798
Practice Address - Fax:856-910-8794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-08
Last Update Date:2024-01-10
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
NJ06511117Medicaid