MEDICARE: ISD RENAL INC

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

General Provider Information

NPI Number	:	1386699445
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ISD RENAL INC

Provider Business Mailing Address
First Line	:	5200 VIRGINIA WAY
Second Line	:	LICENSURE & CERTIFICATION
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-7569
Country	:	US
Telephone Number	:	615-341-6374
Fax Number	:

Provider Business Practice Location Address
First Line	:	7017 S ANTHONY BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46816-2016
Country	:	US
Telephone Number	:	260-447-2220
Fax Number	:	260-447-2044

Authorized Official
Title or Position	:	CHIEF ACCOUNTING OFFICER
Name	:	MR. JAMES K HILGER
Credential	:
Telephone Number	:	253-272-1916

Provider Enumeration Date	:	05/24/2006
Last Update Date	:	11/03/2011

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