Basic Information
| Provider Information | |||||||||
| NPI: | 1427120682 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KIDNEY CONSULTANTS MEDICAL GROUP, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11550 INDIAN HILLS RD | ||||||||
| Address2: | SUITE 371 | ||||||||
| City: | MISSION HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913451252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183651194 | ||||||||
| FaxNumber: | 8188983835 | ||||||||
| Practice Location | |||||||||
| Address1: | 11550 INDIAN HILLS RD | ||||||||
| Address2: | SUITE 371 | ||||||||
| City: | MISSION HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913451252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183651194 | ||||||||
| FaxNumber: | 8188983835 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2006 | ||||||||
| LastUpdateDate: | 11/06/2018 | ||||||||
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| AuthorizedOfficialLastName: | ABDEEN | ||||||||
| AuthorizedOfficialFirstName: | OMARAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8183651194 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | GR0068770 | 05 | CA | MEDICAID |