MEDICARE: DIAMOND DIALYSIS 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1633535	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1659374247
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIAMOND DIALYSIS INC.

Provider Business Mailing Address
First Line	:	9415 S WESTERN AVE
Second Line	:	STE 105
City	:	CHICAGO
State	:	IL
Zip	:	60620-6232
Country	:	US
Telephone Number	:	773-238-5200
Fax Number	:	773-238-5527

Provider Business Practice Location Address
First Line	:	9415 S WESTERN AVE
Second Line	:	STE 105
City	:	CHICAGO
State	:	IL
Zip	:	60620-6232
Country	:	US
Telephone Number	:	773-238-5200
Fax Number	:	773-238-5527

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. EDWIN S. NUNEZ
Credential	:
Telephone Number	:	773-238-5200

Provider Enumeration Date	:	05/27/2005
Last Update Date	:	08/22/2020

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