Basic Information
| Provider Information | |||||||||
| NPI: | 1134316680 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILDRENS KIDNEY SPECIALISTS SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 777 OAKMONT LN | ||||||||
| Address2: | SUITE 1600 | ||||||||
| City: | WESTMONT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605595511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307892550 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1954 1ST ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | HIGHLAND PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600353104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8474333345 | ||||||||
| FaxNumber: | 8474334426 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2007 | ||||||||
| LastUpdateDate: | 01/22/2008 | ||||||||
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| AuthorizedOfficialLastName: | KALLEN | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8474333345 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0210X | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Nephrology |
No ID Information.