Basic Information
| Provider Information | |||||||||
| NPI: | 1083635908 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KIDNEY CARE CONSULTANTS, PSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 716 W BROADWAY | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402022216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022389911 | ||||||||
| FaxNumber: | 5022389912 | ||||||||
| Practice Location | |||||||||
| Address1: | 716 W BROADWAY | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402022216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025957744 | ||||||||
| FaxNumber: | 5025957007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2006 | ||||||||
| LastUpdateDate: | 12/04/2015 | ||||||||
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| AuthorizedOfficialLastName: | BURIDI | ||||||||
| AuthorizedOfficialFirstName: | ABDUL | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | MD/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5022389911 | ||||||||
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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 | 363L00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207RN0300X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 65938649 | 05 | KY | MEDICAID | 200414260A | 05 | IN | MEDICAID | 7100371660 | 05 | KY | MEDICAID |