Provider Demographics
NPI:1033093356
Name:TIDAL DIALYSIS LLC
Entity type:Organization
Organization Name:TIDAL DIALYSIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:PREMILA
Authorized Official - Middle Name:
Authorized Official - Last Name:BHAT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-899-0060
Mailing Address - Street 1:385 SENECA AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-1340
Mailing Address - Country:US
Mailing Address - Phone:718-899-0060
Mailing Address - Fax:718-559-6758
Practice Address - Street 1:336 HIMROD ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-4871
Practice Address - Country:US
Practice Address - Phone:718-899-0060
Practice Address - Fax:718-559-6758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-31
Last Update Date:2025-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment