Provider Demographics
NPI:1235411406
Name:ELLENWOOD DIALYSIS CENTER, LLC
Entity Type:Organization
Organization Name:ELLENWOOD DIALYSIS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:KASSEM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-392-6198
Mailing Address - Street 1:3580 CAMERON PKWY
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7816
Mailing Address - Country:US
Mailing Address - Phone:770-996-6446
Mailing Address - Fax:678-833-3981
Practice Address - Street 1:209 BENNETTE BLVD
Practice Address - Street 2:
Practice Address - City:ELLENWOOD
Practice Address - State:GA
Practice Address - Zip Code:30294-2785
Practice Address - Country:US
Practice Address - Phone:770-996-6446
Practice Address - Fax:678-833-3981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-14
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment