Healthcare Provider Details

I. General information

NPI: 1861733503
Provider Name (Legal Business Name): NORTHWESTERN MEDICAL FACULTY FOUNDATION DIALYSIS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2013
Last Update Date: 03/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 E HURON ST SUITE 12-240
CHICAGO IL
60611-3197
US

IV. Provider business mailing address

1 WORLD TRADE CTR STE 2500
LONG BEACH CA
90831-0002
US

V. Phone/Fax

Practice location:
  • Phone: 312-472-5200
  • Fax: 312-472-5201
Mailing address:
  • Phone: 562-495-8075
  • Fax: 562-495-8076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: THOMAS L. WEINBERG
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 214-736-2730