MEDICARE: ELLICOTT CITY 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 State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1881716785
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELLICOTT CITY DIALYSIS CENTER LLC

Provider Business Mailing Address
First Line	:	3419 PLUM TREE DR
Second Line	:	SUITES 103-106
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21042-3805
Country	:	US
Telephone Number	:	410-750-8426
Fax Number	:	410-750-8428

Provider Business Practice Location Address
First Line	:	3419 PLUM TREE DR
Second Line	:	SUITES 103-106
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21042-3805
Country	:	US
Telephone Number	:	410-750-8426
Fax Number	:	410-750-8428

Authorized Official
Title or Position	:	CFO
Name	:	MR. JASON BOUCHER
Credential	:
Telephone Number	:	978-922-3080

Provider Enumeration Date	:	04/04/2007
Last Update Date	:	03/22/2019

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