MEDICARE: DIALYSIS CLINIC INC.

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	7004207R	NY

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	:	1124040613
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIALYSIS CLINIC INC.

Provider Business Mailing Address
First Line	:	6518 FORT HAMILTON PKWY
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11219-5523
Country	:	US
Telephone Number	:	718-836-8444
Fax Number	:	718-836-0918

Provider Business Practice Location Address
First Line	:	6518 FORT HAMILTON PKWY
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11219-5523
Country	:	US
Telephone Number	:	718-836-8444
Fax Number	:	718-836-0918

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. DONOVAN SCHULTZ
Credential	:
Telephone Number	:	615-327-3061

Provider Enumeration Date	:	07/24/2006
Last Update Date	:	10/04/2023

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