MEDICARE: LIBERTY DIALYSIS - NORTH HAVEN 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	:	1336206408
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIBERTY DIALYSIS - NORTH HAVEN LLC

Provider Business Mailing Address
First Line	:	424 CHURCH ST
Second Line	:	SUITE 1900
City	:	NASHVILLE
State	:	TN
Zip	:	37219-2301
Country	:	US
Telephone Number	:	615-777-8201
Fax Number	:

Provider Business Practice Location Address
First Line	:	510 WASHINGTON AVE
Second Line	:
City	:	NORTH HAVEN
State	:	CT
Zip	:	06473-1313
Country	:	US
Telephone Number	:	203-234-7071
Fax Number	:	203-234-6778

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	THOMAS L. WEINBERG
Credential	:
Telephone Number	:	214-736-2700

Provider Enumeration Date	:	01/01/2007
Last Update Date	:	03/31/2016

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