Provider Demographics
NPI:1326052267
Name:SUNCOAST DIALYSIS CENTER IMC.
Entity Type:Organization
Organization Name:SUNCOAST DIALYSIS CENTER IMC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:WALSH
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:813-972-3722
Mailing Address - Street 1:3500 E FLETCHER AVE
Mailing Address - Street 2:SUITE 122
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-4708
Mailing Address - Country:US
Mailing Address - Phone:813-972-3722
Mailing Address - Fax:813-972-0717
Practice Address - Street 1:3500 E FLETCHER AVE
Practice Address - Street 2:SUITE 122
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-4708
Practice Address - Country:US
Practice Address - Phone:813-972-3722
Practice Address - Fax:813-972-0717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102724Medicare ID - Type Unspecified