MEDICARE: MONTGOMERY RENAL CENTER 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	E2625	MD

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	:	1902801681
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MONTGOMERY RENAL CENTER LLC.

Provider Business Mailing Address
First Line	:	12401 MIDDLEBROOK RD
Second Line	:	STE 160
City	:	GERMANTOWN
State	:	MD
Zip	:	20874-1523
Country	:	US
Telephone Number	:	301-540-6020
Fax Number	:	301-540-6030

Provider Business Practice Location Address
First Line	:	12401 MIDDLEBROOK RD
Second Line	:	STE 160
City	:	GERMANTOWN
State	:	MD
Zip	:	20874-1523
Country	:	US
Telephone Number	:	301-540-6020
Fax Number	:	301-540-6030

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. ALEISTER CORTELING
Credential	:
Telephone Number	:	240-361-0625

Provider Enumeration Date	:	06/17/2005
Last Update Date	:	05/25/2011

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