Provider Demographics
NPI:1629144514
Name:PHYSICIANS CHOICE DIALYSIS OF SELMA, LLC
Entity Type:Organization
Organization Name:PHYSICIANS CHOICE DIALYSIS OF SELMA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASST SECRETARY ASST TREAURER
Authorized Official - Prefix:
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:PALUMBO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-495-8900
Mailing Address - Street 1:PO BOX 534421
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30353-4421
Mailing Address - Country:US
Mailing Address - Phone:610-495-8900
Mailing Address - Fax:610-495-8560
Practice Address - Street 1:201 LINCOLN LN
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:AL
Practice Address - Zip Code:36701-7748
Practice Address - Country:US
Practice Address - Phone:334-875-5436
Practice Address - Fax:334-872-8547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-24
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS2403261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALDIA2614DMedicaid
AL012-438OtherBLUE CROSS ALABAMA
AL012-438OtherBLUE CROSS ALABAMA