Provider Demographics
NPI:1710092564
Name:DIALYSIS CENTERS OF AMERICA - ILLINOIS, INC.
Entity Type:Organization
Organization Name:DIALYSIS CENTERS OF AMERICA - ILLINOIS, INC.
Other - Org Name:RCG ROGERS PARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BLANTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-699-9000
Mailing Address - Street 1:2277 W HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-1922
Mailing Address - Country:US
Mailing Address - Phone:773-262-7147
Mailing Address - Fax:773-262-5124
Practice Address - Street 1:2277 W HOWARD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60645-1922
Practice Address - Country:US
Practice Address - Phone:773-262-7147
Practice Address - Fax:773-262-5124
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRESENIUS MEDICAL CARE HOLDINGS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-20
Last Update Date:2023-10-16
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
IL142522Medicare Oscar/Certification