Basic Information
| Provider Information | |||||||||
| NPI: | 1033578612 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LOUISVILLE KIDNEY CARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 221531 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402521531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025254376 | ||||||||
| FaxNumber: | 4403323844 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 ABRAHAM FLEXNER WAY | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402022877 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025874011 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2016 | ||||||||
| LastUpdateDate: | 02/13/2019 | ||||||||
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| AuthorizedOfficialLastName: | EL KHEIR | ||||||||
| AuthorizedOfficialFirstName: | MOHAMED | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6172919435 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 7100402450 | 05 | KY | MEDICAID |