Provider Demographics
NPI:1750427548
Name:PREMIER DIALYSIS OF FERGUSON
Entity type:Organization
Organization Name:PREMIER DIALYSIS OF FERGUSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDAMMER
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:618-407-2153
Mailing Address - Street 1:132 FOX HILL CT
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-5736
Mailing Address - Country:US
Mailing Address - Phone:618-407-2153
Mailing Address - Fax:
Practice Address - Street 1:800 CHAMBERS RD
Practice Address - Street 2:
Practice Address - City:FERGUSON
Practice Address - State:MO
Practice Address - Zip Code:63135-2133
Practice Address - Country:US
Practice Address - Phone:314-522-8100
Practice Address - Fax:314-524-7826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2008-12-10
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
MO504605403Medicaid
262624Medicare Oscar/Certification