=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669041471
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RARITAN DIALYSIS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2021
-----------------------------------------------------
Last Update Date | 03/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3232 HENRY AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19129-1241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-876-4258
-----------------------------------------------------
Fax | 267-876-4275
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5200 VIRGINIA WAY L&C DEPARTMENT
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37027-7569
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-341-6410
-----------------------------------------------------
Fax | 888-662-8259
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP L&C DEPT
-----------------------------------------------------
Name | SAMUEL T 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 |
-----------------------------------------------------