Basic Information
| Provider Information | |||||||||
| NPI: | 1831262674 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KIDNEY INSTITUTE OF WISCONSIN, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 CENTRAL AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803012838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037857523 | ||||||||
| FaxNumber: | 3034448639 | ||||||||
| Practice Location | |||||||||
| Address1: | 5650 N GREEN BAY AVE | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | GLENDALE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532094446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144315960 | ||||||||
| FaxNumber: | 4144340359 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | LAWSON | ||||||||
| AuthorizedOfficialFirstName: | HERBERT | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3037857521 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 | 42059400 | 05 | WI | MEDICAID |