Basic Information
| Provider Information | |||||||||
| NPI: | 1932587300 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HOPKINSVILLE KIDNEY CARE PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 215 BURLEY AVE | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | HOPKINSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422408725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708890282 | ||||||||
| FaxNumber: | 6027988267 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 BURLEY AVE | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | HOPKINSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422408725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708890282 | ||||||||
| FaxNumber: | 6027988267 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2015 | ||||||||
| LastUpdateDate: | 07/25/2019 | ||||||||
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| AuthorizedOfficialLastName: | WALCZYK | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2708890282 | ||||||||
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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 | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 7100455650 | 05 | KY | MEDICAID |