Provider Demographics
NPI:1720187248
Name:GEM STATE REGIONAL DIALYSIS CENTER
Entity Type:Organization
Organization Name:GEM STATE REGIONAL DIALYSIS CENTER
Other - Org Name:UNIVERSITY OF UTAH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROGRAM ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:HEMMING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-581-8573
Mailing Address - Street 1:PO BOX 27071
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0071
Mailing Address - Country:US
Mailing Address - Phone:801-581-8578
Mailing Address - Fax:208-529-4189
Practice Address - Street 1:2225 TETON PLZ STE A
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6494
Practice Address - Country:US
Practice Address - Phone:208-522-4831
Practice Address - Fax:208-529-4189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDID DOESN'T ISSUE ONE261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID132500Medicare ID - Type Unspecified