Provider Demographics
NPI:1598774929
Name:DIALYSIS OF NORTHERN ILLINOIS LLC
Entity Type:Organization
Organization Name:DIALYSIS OF NORTHERN ILLINOIS LLC
Other - Org Name:MONROE DIALYSIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:O
Authorized Official - Last Name:USILTON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:770-541-7922
Mailing Address - Street 1:5200 VIRGINIA WAY
Mailing Address - Street 2:4TH FLOOR L&C DEPT
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7569
Mailing Address - Country:US
Mailing Address - Phone:615-320-4521
Mailing Address - Fax:
Practice Address - Street 1:114 8TH ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WI
Practice Address - Zip Code:53566-1050
Practice Address - Country:US
Practice Address - Phone:608-325-3585
Practice Address - Fax:608-325-3981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2009-10-19
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
WI1598774929Medicaid
WI1598774929Medicaid