Provider Demographics
NPI:1992427231
Name:PEACHTREE DIALYSIS CENTER, LLC
Entity type:Organization
Organization Name:PEACHTREE DIALYSIS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BABAYEV
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:516-469-7110
Mailing Address - Street 1:3850 HOLCOMB BRIDGE RD STE 435
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CORNERS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-2255
Mailing Address - Country:US
Mailing Address - Phone:516-469-7110
Mailing Address - Fax:
Practice Address - Street 1:3850 HOLCOMB BRIDGE RD STE 435
Practice Address - Street 2:
Practice Address - City:PEACHTREE CORNERS
Practice Address - State:GA
Practice Address - Zip Code:30092-2255
Practice Address - Country:US
Practice Address - Phone:516-469-7110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-14
Last Update Date:2023-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1073059531Medicaid