Provider Demographics
NPI:1881716785
Name:ELLICOTT CITY DIALYSIS CENTER LLC
Entity type:Organization
Organization Name:ELLICOTT CITY DIALYSIS 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 1:3419 PLUM TREE DR
Mailing Address - Street 2:SUITES 103-106
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-3805
Mailing Address - Country:US
Mailing Address - Phone:410-750-8426
Mailing Address - Fax:410-750-8428
Practice Address - Street 1:3419 PLUM TREE DR
Practice Address - Street 2:SUITES 103-106
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-3805
Practice Address - Country:US
Practice Address - Phone:410-750-8426
Practice Address - Fax:410-750-8428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2019-03-22
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
MD412495200Medicaid
MD212560Medicare Oscar/Certification