Basic Information
| Provider Information | |||||||||
| NPI: | 1992823025 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH SHEPHERD KIDNEY CLINIC, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NORTH SHEPHERD KIDNEY CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7272 N SHEPHERD DR | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770912435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136971115 | ||||||||
| FaxNumber: | 7136971116 | ||||||||
| Practice Location | |||||||||
| Address1: | 7272 N SHEPHERD DR | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770912435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136971115 | ||||||||
| FaxNumber: | 7136971116 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SUKI | ||||||||
| AuthorizedOfficialFirstName: | WADI | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 7137909080 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 | 1770885 | 05 | TX | MEDICAID |