Basic Information
| Provider Information | |||||||||
| NPI: | 1710098090 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DAVITA NEPHROLOGY MEDICAL ASSOCIATES OF WASHINGTON | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KIDNEY CARE OF CENTRAL INDIANA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1627 COLE BLVD | ||||||||
| Address2: | BLDG18 | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804013315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036266239 | ||||||||
| FaxNumber: | 8669175396 | ||||||||
| Practice Location | |||||||||
| Address1: | 1140 W JEFFERSON ST | ||||||||
| Address2: | B | ||||||||
| City: | FRANKLIN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461312101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177364337 | ||||||||
| FaxNumber: | 3177366508 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 12/19/2011 | ||||||||
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| AuthorizedOfficialLastName: | GABRIEL | ||||||||
| AuthorizedOfficialFirstName: | ANTHONY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3036266239 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 200865690A | 05 | IN | MEDICAID |