MEDICARE: FORT SMITH REGIONAL DIALYSIS 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

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	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	900522191	OTHER	OK	PHYSICIAN'S

General Provider Information

NPI Number	:	1912900044
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORT SMITH REGIONAL DIALYSIS CENTER, LLC

Provider Business Mailing Address
First Line	:	2201 BROOKEN HILL DR
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72908-8611
Country	:	US
Telephone Number	:	479-755-6700
Fax Number	:	479-755-6704

Provider Business Practice Location Address
First Line	:	1200 CENTRAL ST
Second Line	:
City	:	POTEAU
State	:	OK
Zip	:	74953-2320
Country	:	US
Telephone Number	:	918-647-9373
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	LAURA PALMER
Credential	:
Telephone Number	:	479-755-6700

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	06/13/2012

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