Provider Demographics
NPI:1902801681
Name:MONTGOMERY RENAL CENTER LLC.
Entity Type:Organization
Organization Name:MONTGOMERY RENAL CENTER LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEISTER
Authorized Official - Middle Name:
Authorized Official - Last Name:CORTELING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-361-0625
Mailing Address - Street 1:12401 MIDDLEBROOK RD
Mailing Address - Street 2:STE 160
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20874-1523
Mailing Address - Country:US
Mailing Address - Phone:301-540-6020
Mailing Address - Fax:301-540-6030
Practice Address - Street 1:12401 MIDDLEBROOK RD
Practice Address - Street 2:STE 160
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20874-1523
Practice Address - Country:US
Practice Address - Phone:301-540-6020
Practice Address - Fax:301-540-6030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-17
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDE2625261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD400446900Medicaid
MD400446900Medicaid