MEDICARE: MICHIGAN DIALYSIS SERVICES, 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

General Provider Information

NPI Number	:	1487112942
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHIGAN DIALYSIS SERVICES, LLC

Provider Business Mailing Address
First Line	:	275 N CANTON CENTER RD
Second Line	:
City	:	CANTON
State	:	MI
Zip	:	48187-2901
Country	:	US
Telephone Number	:	734-844-0137
Fax Number	:	734-981-0082

Provider Business Practice Location Address
First Line	:	275 N CANTON CENTER RD
Second Line	:
City	:	CANTON
State	:	MI
Zip	:	48187-2901
Country	:	US
Telephone Number	:	734-844-0137
Fax Number	:	734-981-0082

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	BARRY L. BLANTON
Credential	:
Telephone Number	:	781-699-9000

Provider Enumeration Date	:	03/04/2019
Last Update Date	:	10/19/2023

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