1114035615 NPI number — NORTHEAST NEPHROLOGY CONSULTANTS

Table of content: MACKENZIE ROBERTS (NPI 1518751262)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114035615 NPI number — NORTHEAST NEPHROLOGY CONSULTANTS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEAST NEPHROLOGY CONSULTANTS
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:
1114035615
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3100 THEODORE STREET
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
JOLIET
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60435
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-744-5550
Provider Business Mailing Address Fax Number:
815-744-5428

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3100 THEODORE ST STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOLIET
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60435-0605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-717-8750
Provider Business Practice Location Address Fax Number:
815-717-8751
Provider Enumeration Date:
08/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JOYCE
Authorized Official First Name:
KRISTIN
Authorized Official Middle Name:
L
Authorized Official Title or Position:
SENIOR REVENUE CYCLE SUPERVISOR
Authorized Official Telephone Number:
331-216-1163

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RN0300X , with the licence number: 042.005614 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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