Provider Demographics
NPI:1316993702
Name:COMMUNITY/PHYSICIANS DIALYSIS CENTER FAIRBORN, LIMITED
Entity type:Organization
Organization Name:COMMUNITY/PHYSICIANS DIALYSIS CENTER FAIRBORN, LIMITED
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:S
Authorized Official - Last Name:SPIERS
Authorized Official - Suffix:
Authorized Official - Credentials:RN,CNN
Authorized Official - Phone:937-328-8933
Mailing Address - Street 1:247 S BURNETT RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45505-2639
Mailing Address - Country:US
Mailing Address - Phone:937-328-8921
Mailing Address - Fax:937-525-2466
Practice Address - Street 1:1266 N BROAD ST
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-5549
Practice Address - Country:US
Practice Address - Phone:937-879-0433
Practice Address - Fax:937-879-0589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0674DC261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2337297Medicaid
OH362645Medicare ID - Type UnspecifiedMCR 7/8/2002