Provider Demographics
NPI:1699058552
Name:PHYSICIANS CHOICE DIALYSIS OF LEE COUNTY LLC
Entity type:Organization
Organization Name:PHYSICIANS CHOICE DIALYSIS OF LEE COUNTY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF LEGAL
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-495-8900
Mailing Address - Street 1:211 COMMERCE CT
Mailing Address - Street 2:SUITE 104
Mailing Address - City:POTTSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19464-3483
Mailing Address - Country:US
Mailing Address - Phone:610-495-8900
Mailing Address - Fax:610-495-8560
Practice Address - Street 1:5009 RIVER CHASE DRIVE
Practice Address - Street 2:BUILDING 300
Practice Address - City:PHENIX CITY
Practice Address - State:AL
Practice Address - Zip Code:36867-7484
Practice Address - Country:US
Practice Address - Phone:610-495-8900
Practice Address - Fax:610-495-8560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-27
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL138523Medicaid
AL012653Medicare Oscar/Certification