Provider Demographics
NPI:1780075010
Name:MEDICAL DISTRICT HOME DIALYSIS LLC
Entity type:Organization
Organization Name:MEDICAL DISTRICT HOME DIALYSIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:WEIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-257-6642
Mailing Address - Street 1:1501 S CALIFORNIA AVE
Mailing Address - Street 2:SUITE 119
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-1732
Mailing Address - Country:US
Mailing Address - Phone:773-257-6642
Mailing Address - Fax:
Practice Address - Street 1:1501 S CALIFORNIA AVE
Practice Address - Street 2:SUITE 119
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1732
Practice Address - Country:US
Practice Address - Phone:773-257-6642
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-09
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment