Basic Information
Provider Information | |||||||||
NPI: | 1265541312 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NEPHROLOGY CONSULTANTS LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 745 OLIVE ST | ||||||||
Address2: | SUITE 200 | ||||||||
City: | SHREVEPORT | ||||||||
State: | LA | ||||||||
PostalCode: | 711042246 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3182260809 | ||||||||
FaxNumber: | 3182260812 | ||||||||
Practice Location | |||||||||
Address1: | 745 OLIVE ST | ||||||||
Address2: | SUITE 200 | ||||||||
City: | SHREVEPORT | ||||||||
State: | LA | ||||||||
PostalCode: | 711042246 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3182260809 | ||||||||
FaxNumber: | 3182260812 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/30/2006 | ||||||||
LastUpdateDate: | 12/29/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KILPATRICK | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: | STEPHEN | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 3182260809 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | MD.015694 | LA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
ID | Type | State | Issuer | Description | 1949442 | 05 | LA |   | MEDICAID | 19D0968584 | 01 |   | CLIA | OTHER |