Provider Demographics
NPI:1659830800
Name:ETOWAH DIALYSIS LLC
Entity Type:Organization
Organization Name:ETOWAH DIALYSIS LLC
Other - Org Name:ST. LUKE'S MACUNGIE 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:T
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:ATT: 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 1:2550 ROUTE 100
Practice Address - Street 2:STE 2
Practice Address - City:MACUNGIE
Practice Address - State:PA
Practice Address - Zip Code:18062-9600
Practice Address - Country:US
Practice Address - Phone:610-336-8350
Practice Address - Fax:610-336-8354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-18
Last Update Date:2024-03-07
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
PA1029243170008Medicaid