=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245891670
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ISD RENAL INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2019
-----------------------------------------------------
Last Update Date | 12/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 W FOREST AVE STE G
-----------------------------------------------------
City | ENGLEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07631-4033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-816-9733
-----------------------------------------------------
Fax | 201-816-9735
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5200 VIRGINIA WAY L&C DEPT
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37027-7569
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP, LICENSURE & CERTIFICATION
-----------------------------------------------------
Name | SAMUEL WEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-341-6641
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QE0700X
-----------------------------------------------------
Taxonomy Name | End-Stage Renal Disease (ESRD) Treatment Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------