Basic Information
Provider Information | |||||||||
NPI: | 1477624963 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | THE KIDNEY INSTITUTE, LTD. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2100 CENTRAL AVE | ||||||||
Address2: | SUITE 201 | ||||||||
City: | BOULDER | ||||||||
State: | CO | ||||||||
PostalCode: | 803012838 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3037857523 | ||||||||
FaxNumber: | 3034448639 | ||||||||
Practice Location | |||||||||
Address1: | 601 N 99TH ST | ||||||||
Address2: | SUITE 300 | ||||||||
City: | WAUWATOSA | ||||||||
State: | WI | ||||||||
PostalCode: | 532264339 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4147781623 | ||||||||
FaxNumber: | 4147781631 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/13/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LAWSON | ||||||||
AuthorizedOfficialFirstName: | HERBERT | ||||||||
AuthorizedOfficialMiddleName: | S | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 3037857521 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
ID | Type | State | Issuer | Description | 42056800 | 05 | WI |   | MEDICAID |