Provider Demographics
NPI:1982872248
Name:FRESENIUS MEDICAL CARE COMPREHENSIVE CKD SE
Entity type:Organization
Organization Name:FRESENIUS MEDICAL CARE COMPREHENSIVE CKD SE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT, TREASURE
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:FAWCETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-699-2668
Mailing Address - Street 1:920 WINTER ST
Mailing Address - Street 2:FMCNA CKD SERVICES 3W-16
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-1521
Mailing Address - Country:US
Mailing Address - Phone:781-699-4160
Mailing Address - Fax:781-699-4046
Practice Address - Street 1:360 WALMART DR
Practice Address - Street 2:
Practice Address - City:UNIONTOWN
Practice Address - State:PA
Practice Address - Zip Code:15401-3109
Practice Address - Country:US
Practice Address - Phone:724-832-8169
Practice Address - Fax:724-439-5397
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRESENIUS MEDICAL CARE HOLDINGS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-20
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA133V00000X, 261QE0700X, 363LA2100X, 363LF0000X
261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) TreatmentGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102264056 0001Medicaid
PA137031Medicare UPIN