1477680205 NPI number — KIDNEY SPECIALISTS, P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477680205 NPI number — KIDNEY SPECIALISTS, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KIDNEY SPECIALISTS, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477680205
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/08/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1325 EASTMORELAND AVE
Provider Second Line Business Mailing Address:
SUITE 335
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38104-3519
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-726-1199
Provider Business Mailing Address Fax Number:
901-729-0794

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1325 EASTMORELAND AVE
Provider Second Line Business Practice Location Address:
SUITE 335
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38104-3519
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-726-1199
Provider Business Practice Location Address Fax Number:
901-729-0794
Provider Enumeration Date:
02/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MANSOUR
Authorized Official First Name:
NAWAR
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
901-729-1199

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  MD0000026012 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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