Basic Information
| Provider Information | |||||||||
| NPI: | 1629186168 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DALLAS RENAL GROUP PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3571 W WHEATLAND RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752373461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722745555 | ||||||||
| FaxNumber: | 9722745663 | ||||||||
| Practice Location | |||||||||
| Address1: | 3571 W WHEATLAND RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752373461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722745555 | ||||||||
| FaxNumber: | 9722745663 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 03/11/2015 | ||||||||
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| AuthorizedOfficialLastName: | CHIMATA | ||||||||
| AuthorizedOfficialFirstName: | YUGANDHAR | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9722745555 | ||||||||
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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 | 207RN0300X | L7332 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 173547401 | 05 | TX | MEDICAID | 173547402 | 05 | TX | MEDICAID |