Provider Demographics
NPI:1245324995
Name:UNIVERSITY OF SOUTH FLORIDA DIALYSIS CENTER
Entity type:Organization
Organization Name:UNIVERSITY OF SOUTH FLORIDA DIALYSIS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:UNIT ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:IZZY
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-632-7918
Mailing Address - Street 1:10770 N 46TH STREET SUITE A 100
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33617
Mailing Address - Country:US
Mailing Address - Phone:813-632-7918
Mailing Address - Fax:813-632-7941
Practice Address - Street 1:10770 N 46TH STREET SUITE A 100
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33617
Practice Address - Country:US
Practice Address - Phone:813-632-7918
Practice Address - Fax:813-632-7941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2008-06-17
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
FL030279101Medicaid
FL102636Medicare Oscar/Certification