1255509469 NPI number — KIDNEY & HYPERTENSION INSTITUTE OF ST. GEORGE PLLC

Table of content: (NPI 1255509469)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255509469 NPI number — KIDNEY & HYPERTENSION INSTITUTE OF ST. GEORGE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KIDNEY & HYPERTENSION INSTITUTE OF ST. GEORGE 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:
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:
1255509469
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301 N 200 E
Provider Second Line Business Mailing Address:
SUITE 1D
Provider Business Mailing Address City Name:
ST GEORGE
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84770-3010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
435-652-1135
Provider Business Mailing Address Fax Number:
435-652-1190

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1127 BROADWAY
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98402-3519
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-816-6535
Provider Business Practice Location Address Fax Number:
206-816-6586
Provider Enumeration Date:
02/11/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MERCADO
Authorized Official First Name:
CARLOS
Authorized Official Middle Name:
ALBERTO
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
435-652-1135

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  6787613-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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