1427509751 NPI number — MEDICINE AND NEPHROLOGY CLINIC LLC

Table of content: DR. HANYA HARRIS BLUESTONE PH.D. (NPI 1487693388)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427509751 NPI number — MEDICINE AND NEPHROLOGY CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICINE AND NEPHROLOGY CLINIC 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:
1427509751
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/01/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
700 W CENTRAL AVE STE 206
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL DORADO
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67042-2186
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
316-452-5455
Provider Business Mailing Address Fax Number:
316-321-0503

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 W CENTRAL AVE STE 206
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL DORADO
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67042-2186
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-452-5455
Provider Business Practice Location Address Fax Number:
316-321-0503
Provider Enumeration Date:
10/21/2016

Additional Information

Authorized Official

Authorized Official Last Name:
OKONKWO
Authorized Official First Name:
NDUBUEZE
Authorized Official Middle Name:
FIDELIS
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
316-452-5455

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1972118 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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