Basic Information
| Provider Information | |||||||||
| NPI: | 1124142971 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KIDNEY CARE CENTER, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 4908 | ||||||||
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| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082361600 | ||||||||
| FaxNumber: | 2082366695 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 S. UNIVERSITY | ||||||||
| Address2: | SUITE 508 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082361600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ALAM | ||||||||
| AuthorizedOfficialFirstName: | MUHAMMAD | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5017723018 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | AR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
No ID Information.