MEDICARE: SOUTHEASTERN INDIANA DIALYSIS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043475312
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHEASTERN INDIANA DIALYSIS LLC

Provider Business Mailing Address
First Line	:	5200 VIRGINIA WAY
Second Line	:	STE 400 L&C
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-7569
Country	:	US
Telephone Number	:	615-320-4521
Fax Number	:	866-594-2894

Provider Business Practice Location Address
First Line	:	2340 NORTH STATE HIGHWAY 7
Second Line	:
City	:	NORTH VERNON
State	:	IN
Zip	:	47265-7183
Country	:	US
Telephone Number	:	812-352-8150
Fax Number	:	812-352-8204

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	JIM HILGER
Credential	:
Telephone Number	:	253-382-1919

Provider Enumeration Date	:	07/25/2008
Last Update Date	:	10/16/2009

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