1174548028 NPI number — NORTHLAKE NEPHROLOGY PLLC

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 1174548028 NPI number — NORTHLAKE NEPHROLOGY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHLAKE NEPHROLOGY PLLC
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:
1174548028
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/16/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
125 HENRY LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOORESVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28117-8767
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-660-8878
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1665 DAVIE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STATESVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28677-3519
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-978-0052
Provider Business Practice Location Address Fax Number:
704-978-0054
Provider Enumeration Date:
07/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SALMAN
Authorized Official First Name:
SINASI
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DOCTOR
Authorized Official Telephone Number:
704-978-0052

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X , with the licence number:  200200166 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 89131MK , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 89131MK . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: DF7259 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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