MEDICARE: SUNCOAST DIALYSIS CENTER IMC.

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		FL

General Provider Information

NPI Number	:	1326052267
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUNCOAST DIALYSIS CENTER IMC.

Provider Business Mailing Address
First Line	:	3500 E FLETCHER AVE
Second Line	:	SUITE 122
City	:	TAMPA
State	:	FL
Zip	:	33613-4708
Country	:	US
Telephone Number	:	813-972-3722
Fax Number	:	813-972-0717

Provider Business Practice Location Address
First Line	:	3500 E FLETCHER AVE
Second Line	:	SUITE 122
City	:	TAMPA
State	:	FL
Zip	:	33613-4708
Country	:	US
Telephone Number	:	813-972-3722
Fax Number	:	813-972-0717

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. WALTER LAWRENCE WALSH JR.
Credential	:
Telephone Number	:	813-972-3722

Provider Enumeration Date	:	07/28/2006
Last Update Date	:	08/22/2020

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