Provider Demographics
NPI:1710910674
Name:HOME DIALYSIS SERVICES OF SANDUSKY INC.
Entity Type:Organization
Organization Name:HOME DIALYSIS SERVICES OF SANDUSKY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GWANG
Authorized Official - Middle Name:OCH
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-627-0477
Mailing Address - Street 1:2819 HAYES AVE STE 8
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-5391
Mailing Address - Country:US
Mailing Address - Phone:419-627-0477
Mailing Address - Fax:419-627-0466
Practice Address - Street 1:2819 HAYES AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-5391
Practice Address - Country:US
Practice Address - Phone:419-627-8403
Practice Address - Fax:419-627-1962
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOME DIALYSIS SERVICES OF SANDUSKY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-07
Last Update Date:2019-12-13
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
OH000000340065OtherANTHEM
OH2472104Medicaid
OH2472104Medicaid