Provider Demographics
NPI:1053599357
Name:SOMERVILLE DIALYSIS CENTER LLC
Entity type:Organization
Organization Name:SOMERVILLE DIALYSIS CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR DIRECTOR LICENSURE&CERTIFICATION
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:WEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-341-6641
Mailing Address - Street 1:5200 VIRGINIA WAY
Mailing Address - Street 2:L&C DEPT
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7569
Mailing Address - Country:US
Mailing Address - Phone:615-320-4514
Mailing Address - Fax:866-594-9961
Practice Address - Street 1:9045 US HIGHWAY 64
Practice Address - Street 2:STE 102
Practice Address - City:LAKELAND
Practice Address - State:TN
Practice Address - Zip Code:38002-8394
Practice Address - Country:US
Practice Address - Phone:901-213-2955
Practice Address - Fax:901-213-1724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-08
Last Update Date:2023-08-17
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
MS08377719Medicaid
TN0442678Medicaid
AR177215134Medicaid
TN0442678Medicaid
AR177215134Medicaid