Provider Demographics
NPI:1922318666
Name:DIALYSIS MANAGEMENT GROUP LLC
Entity Type:Organization
Organization Name:DIALYSIS MANAGEMENT GROUP LLC
Other - Org Name:PORCUPINE DIALYSIS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:RADA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-390-0910
Mailing Address - Street 1:HCR 49 BOX 82C
Mailing Address - Street 2:
Mailing Address - City:PORCUPINE
Mailing Address - State:SD
Mailing Address - Zip Code:57772-0000
Mailing Address - Country:US
Mailing Address - Phone:605-718-0392
Mailing Address - Fax:
Practice Address - Street 1:HCR 49
Practice Address - Street 2:
Practice Address - City:PORCUPINE
Practice Address - State:SD
Practice Address - Zip Code:57772-0000
Practice Address - Country:US
Practice Address - Phone:605-718-0392
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-15
Last Update Date:2013-11-22
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
SD5400390Medicaid
SD432514Medicare Oscar/Certification