Basic Information
| Provider Information | |||||||||
| NPI: | 1831281849 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HUNTSVILLE RENAL CLINIC, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 810 FRANKLIN ST SE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358014311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2565337676 | ||||||||
| FaxNumber: | 2565333171 | ||||||||
| Practice Location | |||||||||
| Address1: | 810 FRANKLIN ST SE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358014311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2565337676 | ||||||||
| FaxNumber: | 2565333171 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 01/26/2010 | ||||||||
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| AuthorizedOfficialLastName: | SMELSER | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2565337676 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 | 000046537 | 05 | AL | MEDICAID | 529908020 | 05 | AL | MEDICAID |