MEDICARE: INDEPENDENT DIALYSIS FOUNDATION, 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	E2544R	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
2	590077-01	OTHER	MD	CAREFIRST
3	21506	OTHER	MD	JAI MEDICAL
4	215143	OTHER	MD	MDIPA
5	PS4	OTHER	MD	FEP
6	0704865003	OTHER	MD	CIGNA
7	0125608	OTHER	MD	AETNA
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1942218797
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDEPENDENT DIALYSIS FOUNDATION, INC

Provider Business Mailing Address
First Line	:	840 HOLLINS ST
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21201-1024
Country	:	US
Telephone Number	:	410-468-0900
Fax Number	:	410-468-0911

Provider Business Practice Location Address
First Line	:	804 LANDMARK DR
Second Line	:	SUITE 112
City	:	GLEN BURNIE
State	:	MD
Zip	:	21061-4486
Country	:	US
Telephone Number	:	410-468-0900
Fax Number	:	410-468-0911

Authorized Official
Title or Position	:	DIRECTOR OF INFORMATION SYSTEMS
Name	:	ZEKE AYELE
Credential	:
Telephone Number	:	410-468-0900

Provider Enumeration Date	:	08/04/2006
Last Update Date	:	07/16/2007

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