MEDICARE: WEST NASSAU DIALYSIS CENTER, 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	2910200R	NY

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
2	022223	OTHER	NY	EMPIRE BCBS

General Provider Information

NPI Number	:	1396744165
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST NASSAU DIALYSIS CENTER, INC

Provider Business Mailing Address
First Line	:	2314 COLLEGE POINT BLVD
Second Line	:
City	:	COLLEGE POINT
State	:	NY
Zip	:	11356-2526
Country	:	US
Telephone Number	:	516-823-4444
Fax Number	:	516-823-4445

Provider Business Practice Location Address
First Line	:	75 ROCKAWAY AVE
Second Line	:
City	:	VALLEY STREAM
State	:	NY
Zip	:	11580-5808
Country	:	US
Telephone Number	:	516-823-4444
Fax Number	:	516-823-4445

Authorized Official
Title or Position	:	PRESIDENT
Name	:	J. GANESH BHAT
Credential	:	MD
Telephone Number	:	718-366-1111

Provider Enumeration Date	:	07/14/2005
Last Update Date	:	03/04/2015

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