1962435644 NPI number — MIDWEST KIDNEY CARE, LLC

Table of content: STACIE ANNE HUNTER RD (NPI 1013257351)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962435644 NPI number — MIDWEST KIDNEY CARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIDWEST KIDNEY CARE, LLC
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:
6
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:
1962435644
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/01/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
335 MAHN CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAK CREEK
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53154-2155
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-762-2020
Provider Business Mailing Address Fax Number:
414-762-2024

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2050 CONTINENTAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST BEND
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53095-7848
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-306-2700
Provider Business Practice Location Address Fax Number:
262-306-2704
Provider Enumeration Date:
07/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KURZ
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
A
Authorized Official Title or Position:
V.P. OPERATIONS
Authorized Official Telephone Number:
414-762-2020

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 42058000 . This is a "MEDICAID PROVIDER NUMBER" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 42058000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5222544 . This is a "MEDICARE PROVIDER NUMBER" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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