1982095626 NPI number — THE KIDNEY CENTER OF SOUTH PHILADELPHIA LLC

Table of content: (NPI 1982095626)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982095626 NPI number — THE KIDNEY CENTER OF SOUTH PHILADELPHIA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE KIDNEY CENTER OF SOUTH PHILADELPHIA 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:
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:
1982095626
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/17/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1930 S BROAD ST
Provider Second Line Business Mailing Address:
UNIT 7
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19145-2328
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-463-3120
Provider Business Mailing Address Fax Number:
215-463-3107

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1930 S BROAD ST
Provider Second Line Business Practice Location Address:
UNIT 7
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19145-2328
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-463-3120
Provider Business Practice Location Address Fax Number:
215-463-3107
Provider Enumeration Date:
02/17/2015

Additional Information

Authorized Official

Authorized Official Last Name:
COUSINS
Authorized Official First Name:
SHARI
Authorized Official Middle Name:
K
Authorized Official Title or Position:
SR. VP OF CLINICAL & REGULATORY
Authorized Official Telephone Number:
978-922-3080

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: 1030464270001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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