Provider Demographics
NPI:1831249440
Name:ST JOSEPH'S DIALYSIS
Entity type:Organization
Organization Name:ST JOSEPH'S DIALYSIS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:WAITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-703-6777
Mailing Address - Street 1:973 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-2524
Mailing Address - Country:US
Mailing Address - Phone:315-703-6700
Mailing Address - Fax:315-703-6762
Practice Address - Street 1:3993 WEST RD
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045-1843
Practice Address - Country:US
Practice Address - Phone:607-662-0140
Practice Address - Fax:607-662-0519
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST JOSEPHS HOSPITAL HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-12
Last Update Date:2009-07-31
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
NY02995893Medicaid
NY00315013Medicaid
333551Medicare Oscar/Certification