Basic Information
| Provider Information | |||||||||
| NPI: | 1043555360 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KIDNEY HEALTH CARE PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19 OLT AVE | ||||||||
| Address2: | |||||||||
| City: | PEKIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 615546214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096426705 | ||||||||
| FaxNumber: | 3093472623 | ||||||||
| Practice Location | |||||||||
| Address1: | 19 OLT AVE | ||||||||
| Address2: | |||||||||
| City: | PEKIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 615546214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096426705 | ||||||||
| FaxNumber: | 3093472623 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2012 | ||||||||
| LastUpdateDate: | 11/28/2012 | ||||||||
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| AuthorizedOfficialLastName: | USMAN | ||||||||
| AuthorizedOfficialFirstName: | AHSAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3096426705 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 036-121212 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
No ID Information.