1134260870 NPI number — KIDNEY DISEASE CONSULTANTS, P.C.

Table of content: (NPI 1134260870)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134260870 NPI number — KIDNEY DISEASE CONSULTANTS, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KIDNEY DISEASE CONSULTANTS, 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:
1134260870
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 366
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHAVEN
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38671-0005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-536-1859
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1890 GOODMAN RD E
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
SOUTHAVEN
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38671-9504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-536-1859
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ADELEYE
Authorized Official First Name:
OLUFEMI
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
901-289-5206

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3724848 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 231379826 . This is a "BLUE CROSS" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 06530562 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4093914 . This is a "BCBS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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