MEDICARE: HOME DIALYSIS SERVICES OF SANDUSKY 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000340065	OTHER	OH	ANTHEM
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710910674
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOME DIALYSIS SERVICES OF SANDUSKY INC.

Provider Business Mailing Address
First Line	:	2819 HAYES AVE STE 8
Second Line	:
City	:	SANDUSKY
State	:	OH
Zip	:	44870-5391
Country	:	US
Telephone Number	:	419-627-0477
Fax Number	:	419-627-0466

Provider Business Practice Location Address
First Line	:	2819 HAYES AVE
Second Line	:	SUITE 2
City	:	SANDUSKY
State	:	OH
Zip	:	44870-5391
Country	:	US
Telephone Number	:	419-627-8403
Fax Number	:	419-627-1962

Authorized Official
Title or Position	:	PRESIDENT
Name	:	GWANG OCH KIM
Credential	:	MD
Telephone Number	:	419-627-0477

Provider Enumeration Date	:	07/07/2006
Last Update Date	:	12/13/2019

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