Provider Demographics
NPI:1861424707
Name:PERITONEAL DIALYSIS CONCEPTS INC.
Entity type:Organization
Organization Name:PERITONEAL DIALYSIS CONCEPTS INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:F
Authorized Official - Last Name:SHEPERD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-642-5038
Mailing Address - Street 1:30100 TELEGRAPH RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BINGHAM FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-4516
Mailing Address - Country:US
Mailing Address - Phone:248-723-0224
Mailing Address - Fax:248-642-7852
Practice Address - Street 1:1 ELIZABETH PL. 627 EDWIN C MOSES BLVD
Practice Address - Street 2:SUITE 2B
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-1445
Practice Address - Country:US
Practice Address - Phone:937-275-7402
Practice Address - Fax:937-424-3581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2009-09-09
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
OH000000002891OtherANTHEM
6800191OtherUNITED HEALTH CARE
OH0133439Medicaid
OH0133439Medicaid
OH362542Medicare Oscar/Certification