Provider Demographics
NPI:1710252614
Name:AFFILIATED DIALYSIS OF GLEN ELLYN LLC
Entity Type:Organization
Organization Name:AFFILIATED DIALYSIS OF GLEN ELLYN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER REPRESENTATIVE
Authorized Official - Prefix:MR
Authorized Official - First Name:CURT
Authorized Official - Middle Name:D
Authorized Official - Last Name:ANLIKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-942-1111
Mailing Address - Street 1:800 ROOSEVELT RD
Mailing Address - Street 2:E320
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-5839
Mailing Address - Country:US
Mailing Address - Phone:630-942-1111
Mailing Address - Fax:630-942-1112
Practice Address - Street 1:800 ROOSEVELT RD
Practice Address - Street 2:E320
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-5875
Practice Address - Country:US
Practice Address - Phone:630-942-1111
Practice Address - Fax:630-942-1112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-12
Last Update Date:2015-02-27
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
IL142752Medicare Oscar/Certification