MEDICARE: DIALYSIS CENTERS OF AMERICA - ILLINOIS, 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

General Provider Information

NPI Number	:	1174638928
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIALYSIS CENTERS OF AMERICA - ILLINOIS, INC.

Provider Business Mailing Address
First Line	:	5401 S WENTWORTH AVE STE 18
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60609-6349
Country	:	US
Telephone Number	:	773-548-5714
Fax Number	:	773-548-5752

Provider Business Practice Location Address
First Line	:	5401 S WENTWORTH AVE STE 18
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60609-6349
Country	:	US
Telephone Number	:	773-548-5714
Fax Number	:	773-548-5752

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	BARRY L. BLANTON
Credential	:
Telephone Number	:	781-699-9000

Provider Enumeration Date	:	08/20/2006
Last Update Date	:	10/16/2023

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