MEDICARE: MIDWOOD DIALYSIS, 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	:	1356674857
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDWOOD DIALYSIS, LLC

Provider Business Mailing Address
First Line	:	1122 CONEY ISLAND AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11230-2345
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1122 CONEY ISLAND AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11230-2345
Country	:	US
Telephone Number	:	347-203-0430
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. JACK MEISELS
Credential	:
Telephone Number	:	347-203-0430

Provider Enumeration Date	:	09/15/2009
Last Update Date	:	01/13/2015

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