Provider Demographics
NPI:1215969563
Name:PERITONIAL DIALYSIS ON NORTH AMERICA,LLC
Entity type:Organization
Organization Name:PERITONIAL DIALYSIS ON NORTH AMERICA,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:M
Authorized Official - Last Name:SWAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-750-5555
Mailing Address - Street 1:1030 ST.GEORGE AVE
Mailing Address - Street 2:LOWER LEVEL 1
Mailing Address - City:AVENEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07001
Mailing Address - Country:US
Mailing Address - Phone:732-750-5555
Mailing Address - Fax:732-750-5550
Practice Address - Street 1:1030 ST.GEORGE AVE
Practice Address - Street 2:LOWER LEVEL 1
Practice Address - City:AVENEL
Practice Address - State:NJ
Practice Address - Zip Code:07001
Practice Address - Country:US
Practice Address - Phone:732-750-5555
Practice Address - Fax:732-750-5550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2008-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA068150207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8974004Medicaid