Basic Information
| Provider Information | |||||||||
| NPI: | 1124287180 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEPHROLOGY AND HYPERTENSION CONSULTANTS SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1480 RENAISSANCE DR | ||||||||
| Address2: | SUITE 211 | ||||||||
| City: | PARK RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600681332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138908004 | ||||||||
| FaxNumber: | 8132909691 | ||||||||
| Practice Location | |||||||||
| Address1: | 1480 RENAISSANCE DR | ||||||||
| Address2: | SUITE 211 | ||||||||
| City: | PARK RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600681332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138908004 | ||||||||
| FaxNumber: | 8132909691 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2008 | ||||||||
| LastUpdateDate: | 11/17/2009 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | PHYSICIAN/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8138908004 | ||||||||
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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 | 2080P0210X | 036051280 | IL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Nephrology | 207RN0300X | 036051280 | IL | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 036051280 | 05 | IL | MEDICAID |