1700420361 NPI number — RENALYTIX AI, INC.

Table of content: (NPI 1700420361)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700420361 NPI number — RENALYTIX AI, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RENALYTIX AI, INC.
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:
1700420361
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/31/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2460
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAROL STREAM
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60132-2460
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-861-1383
Provider Business Mailing Address Fax Number:
201-345-1291

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30-02 48TH AVE.
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
LONG ISLAND CITY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11101-3432
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
646-397-3970
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/06/2019

Additional Information

Authorized Official

Authorized Official Last Name:
MCCULLOUGH
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
888-203-2725

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 116021000 . 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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