MEDICARE: NXSTAGE ORLANDO SOUTH, 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	:	1629491501
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NXSTAGE ORLANDO SOUTH, LLC

Provider Business Mailing Address
First Line	:	350 MERRIMACK ST
Second Line	:
City	:	LAWRENCE
State	:	MA
Zip	:	01843-1748
Country	:	US
Telephone Number	:	978-530-4006
Fax Number	:

Provider Business Practice Location Address
First Line	:	14522 LANDSTAR BLVD
Second Line	:	SUITE 102
City	:	ORLANDO
State	:	FL
Zip	:	32824-6450
Country	:	US
Telephone Number	:	978-530-4006
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	JEFF MURRAY
Credential	:
Telephone Number	:	978-530-4006

Provider Enumeration Date	:	01/28/2014
Last Update Date	:	07/17/2014

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