Healthcare Provider Details

I. General information

NPI: 1598774929
Provider Name (Legal Business Name): DIALYSIS OF NORTHERN ILLINOIS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 10/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 8TH ST
MONROE WI
53566-1050
US

IV. Provider business mailing address

5200 VIRGINIA WAY 4TH FLOOR L&C DEPT
BRENTWOOD TN
37027-7569
US

V. Phone/Fax

Practice location:
  • Phone: 608-325-3585
  • Fax: 608-325-3981
Mailing address:
  • Phone: 615-320-4521
  • Fax:

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 O USILTON JR.
Title or Position: SR VICE PRESIDENT
Credential:
Phone: 770-541-7922