Provider Demographics
NPI:1205052735
Name:MMB DIALYSIS, LLC
Entity type:Organization
Organization Name:MMB DIALYSIS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:T
Authorized Official - Last Name:SPARROW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-676-8123
Mailing Address - Street 1:200 E. PENNSYLVANIA AVE.
Mailing Address - Street 2:SUITE 212
Mailing Address - City:PEORA
Mailing Address - State:IL
Mailing Address - Zip Code:61603
Mailing Address - Country:US
Mailing Address - Phone:309-676-8123
Mailing Address - Fax:309-676-8455
Practice Address - Street 1:523 E GRANT ST
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-3313
Practice Address - Country:US
Practice Address - Phone:309-836-1662
Practice Address - Fax:309-836-1661
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIDWEST KIDNEY CENTERS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-17
Last Update Date:2008-09-03
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
IL=========001Medicaid
142591Medicare UPIN