Basic Information
| Provider Information | |||||||||
| NPI: | 1467672261 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KIDNEY CARE PHYSICIANS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 875 OAK ST SE STE 5070 | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973013975 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035618565 | ||||||||
| FaxNumber: | 5035618560 | ||||||||
| Practice Location | |||||||||
| Address1: | 875 OAK ST SE STE 5070 | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973013975 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035618565 | ||||||||
| FaxNumber: | 5035618560 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2007 | ||||||||
| LastUpdateDate: | 09/21/2011 | ||||||||
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| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | EVAL | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 5035618565 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 11594223 | OR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 100101 | 05 | OR | MEDICAID |