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General NPI Number Information
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NPI Number | 1184868051
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Entity Type | Organization
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Legal Business Name | PRODIGY DIALYSIS
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Dates
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Enumeration Date | 04/23/2009
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Last Update Date | 02/05/2013
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Provider Practice Location Address
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Address Line | 1100 W HIGH ST
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City | EBENSBURG
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State | PA
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Zip | 15931-1706
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Country | US
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Telephone | 814-419-8107
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Fax | 814-419-8108
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Provider Business Mailing Address
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Address Line | 88 OSBORNE ST
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City | JOHNSTOWN
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State | PA
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Zip | 15905-4146
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Country | US
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Telephone | 814-539-0798
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Fax | 814-536-4751
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. GEORGE J FREM
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Credential | MD
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Telephone | 814-539-0798
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QE0700X
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Taxonomy Name | End-Stage Renal Disease (ESRD) Treatment Clinic/Center
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License Number | MD042825E
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License Number State | PA
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