Provider Demographics
NPI:1871863738
Name:ATLANTIC DIALYSIS MANAGEMENT SERVICES, LLC
Entity Type:Organization
Organization Name:ATLANTIC DIALYSIS MANAGEMENT SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:
Authorized Official - First Name:JODUMUTT
Authorized Official - Middle Name:GANESH
Authorized Official - Last Name:BHAT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-821-3182
Mailing Address - Street 1:2314 COLLEGE POINT BLVD
Mailing Address - Street 2:
Mailing Address - City:COLLEGE POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11356-2526
Mailing Address - Country:US
Mailing Address - Phone:718-483-7428
Mailing Address - Fax:718-821-3182
Practice Address - Street 1:2314 COLLEGE POINT BLVD
Practice Address - Street 2:
Practice Address - City:COLLEGE POINT
Practice Address - State:NY
Practice Address - Zip Code:11356-2526
Practice Address - Country:US
Practice Address - Phone:718-483-7428
Practice Address - Fax:718-821-3182
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-10
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7003241R261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03352696OtherNYS DOH SERVICE BUREAU PROVIDER ID