=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902907652
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PERSONAL DIALYSIS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2006
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 747 CAMBRIDGE ST
-----------------------------------------------------
City | BRIGHTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02135-2926
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-783-3800
-----------------------------------------------------
Fax | 617-783-0255
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 W CUMMINGS PARK SUITE 2250
-----------------------------------------------------
City | WOBURN
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01801-6519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-932-8891
-----------------------------------------------------
Fax | 617-783-0255
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MARTIN L. GELMAN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 781-932-8891
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QE0700X
-----------------------------------------------------
Taxonomy Name | End-Stage Renal Disease (ESRD) Treatment Clinic/Center
-----------------------------------------------------
License Number | EQZF
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------