1891707196 NPI number — OAK PARK KIDNEY CENTER LLC

Table of content: (NPI 1891707196)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891707196 NPI number — OAK PARK KIDNEY CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OAK PARK KIDNEY CENTER 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:
MAPLE AVENUE KIDNEY CENTER
Provider Other Organization Name Type Code:
3
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:
1891707196
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
610 S MAPLE AVE
Provider Second Line Business Mailing Address:
STE 4100
Provider Business Mailing Address City Name:
OAK PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60304-1091
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-660-4100
Provider Business Mailing Address Fax Number:
708-660-4103

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
610 S MAPLE AVE
Provider Second Line Business Practice Location Address:
STE 4100
Provider Business Practice Location Address City Name:
OAK PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60304-1091
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-660-4100
Provider Business Practice Location Address Fax Number:
708-660-4103
Provider Enumeration Date:
08/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SYED SHAH
Authorized Official First Name:
KAREEM
Authorized Official Middle Name:
M
Authorized Official Title or Position:
UNIT DIRECTOR
Authorized Official Telephone Number:
708-660-4100

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X , with the licence number:  142644 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com