Provider Demographics
NPI:1255754677
Name:ELLICOTT KIDNEY CENTER LLC
Entity type:Organization
Organization Name:ELLICOTT KIDNEY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-922-3080
Mailing Address - Street 1:3000 N RIDGE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-3311
Mailing Address - Country:US
Mailing Address - Phone:410-465-0273
Mailing Address - Fax:410-465-0360
Practice Address - Street 1:3000 N RIDGE RD
Practice Address - Street 2:SUITE A
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-3311
Practice Address - Country:US
Practice Address - Phone:410-465-0273
Practice Address - Fax:410-465-0360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-22
Last Update Date:2019-03-21
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
MD422934700Medicaid