MEDICARE: SOUTH GESSNER DIALYSIS FACILITY

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	008322	TX

General Provider Information

NPI Number	:	1255385431
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH GESSNER DIALYSIS FACILITY

Provider Business Mailing Address
First Line	:	8800 BISSONNET
Second Line	:	SUITE A
City	:	HOUSTON
State	:	TX
Zip	:	77074-2435
Country	:	US
Telephone Number	:	713-773-1717
Fax Number	:	713-773-1716

Provider Business Practice Location Address
First Line	:	8800 BISSONNET
Second Line	:	SUITE A
City	:	HOUSTON
State	:	TX
Zip	:	77074-2435
Country	:	US
Telephone Number	:	713-773-1717
Fax Number	:	713-773-1716

Authorized Official
Title or Position	:	PRESIDENT
Name	:	WISAM ELHAJ
Credential	:
Telephone Number	:	713-773-1717

Provider Enumeration Date	:	05/20/2006
Last Update Date	:	04/01/2008

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