Basic Information
| Provider Information | |||||||||
| NPI: | 1881067973 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MIDLAND KIDNEY CARE PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PERMIAN NEPHROLOGY ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3302 W GOLF COURSE RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | MIDLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797035110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4325222304 | ||||||||
| FaxNumber: | 4325222307 | ||||||||
| Practice Location | |||||||||
| Address1: | 3302 W GOLF COURSE RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | MIDLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797035110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4325222304 | ||||||||
| FaxNumber: | 4325222307 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2015 | ||||||||
| LastUpdateDate: | 01/28/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | FOLKERT | ||||||||
| AuthorizedOfficialFirstName: | VAUGHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7188286840 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 01/28/2020 | ||||||||
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 | 365431101 | 05 | TX | MEDICAID | 00Y9Y6 | 01 | TX | BCBSTX | OTHER |