Provider Demographics
NPI:1104102839
Name:FREEDOM HOME DIALYSIS, LLC
Entity type:Organization
Organization Name:FREEDOM HOME DIALYSIS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER AND MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRANISLAV
Authorized Official - Middle Name:S
Authorized Official - Last Name:ROMANIC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-663-9570
Mailing Address - Street 1:45 THOMAS JOHNSON DR
Mailing Address - Street 2:SUITE 211
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4425
Mailing Address - Country:US
Mailing Address - Phone:301-624-1054
Mailing Address - Fax:301-663-9571
Practice Address - Street 1:45 THOMAS JOHNSON DR
Practice Address - Street 2:SUITE 211
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4425
Practice Address - Country:US
Practice Address - Phone:301-624-1054
Practice Address - Fax:301-663-9571
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDE2661261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD419939100Medicaid