1467036590 NPI number — KIDNEY CLINIC OF NORTH FLORIDA PLLC

Table of content: (NPI 1467036590)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467036590 NPI number — KIDNEY CLINIC OF NORTH FLORIDA PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KIDNEY CLINIC OF NORTH FLORIDA 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:
1467036590
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/10/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1260 BEACH BLVD STE 3-422
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32250-3406
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-744-4448
Provider Business Mailing Address Fax Number:
904-744-4048

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6885 BELFORT OAKS PL STE 230
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32216-6283
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-593-5333
Provider Business Practice Location Address Fax Number:
904-593-5334
Provider Enumeration Date:
05/05/2021

Additional Information

Authorized Official

Authorized Official Last Name:
TANDON
Authorized Official First Name:
GAURAV
Authorized Official Middle Name:
Authorized Official Title or Position:
MD
Authorized Official Telephone Number:
216-692-1956

Provider Taxonomy Codes

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

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

  • Identifier: 118278300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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