MEDICARE: NORTHWEST DETROIT DIALYSIS CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	000000003402	OTHER	CAPE
2	1008733	OTHER	OMNICARE
3	09457	OTHER	BLUE CROSS SECONDARY
4	14296	OTHER	M CARE
5	08954	OTHER	FED BLUE CROSS PRIMARY
6	10078540001	OTHER	WELLNESS
7	232544	OTHER	HAP
8	138129	OTHER	PREFERRED CHOICE
9	5066	OTHER	GREATLAKES
10	08954	OTHER	BLUE CROSS PRIMARY
11	138129	OTHER	CARE CHOICES
12	09457	OTHER	FED BLUE CROSS SECONDARY
13	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
14	P09457	OTHER	BLUE CARE NETWORK

General Provider Information

NPI Number	:	1083634471
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHWEST DETROIT DIALYSIS CENTER, LLC

Provider Business Mailing Address
First Line	:	30100 TELEGRAPH RD
Second Line	:	SUITE 200
City	:	BINGHAM FARMS
State	:	MI
Zip	:	48025-4514
Country	:	US
Telephone Number	:	248-642-5038
Fax Number	:	248-642-7140

Provider Business Practice Location Address
First Line	:	7800 W OUTER DR
Second Line	:	SUITE 190
City	:	DETROIT
State	:	MI
Zip	:	48235-3461
Country	:	US
Telephone Number	:	313-270-9239
Fax Number	:	313-270-9238

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MR. DAVID F SHEPHERD
Credential	:
Telephone Number	:	248-642-5038

Provider Enumeration Date	:	07/20/2006
Last Update Date	:	03/04/2015

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