Provider Demographics
NPI:1073517785
Name:BAY AREA KIDNEY DISEASE PHYSICIANS,LLP
Entity Type:Organization
Organization Name:BAY AREA KIDNEY DISEASE PHYSICIANS,LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICKY
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUTHARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-882-9278
Mailing Address - Street 1:614 FURMAN AVE
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78404-2325
Mailing Address - Country:US
Mailing Address - Phone:361-882-9278
Mailing Address - Fax:361-882-9279
Practice Address - Street 1:614 FURMAN AVE
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78404-2325
Practice Address - Country:US
Practice Address - Phone:361-882-9278
Practice Address - Fax:361-882-9279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00H88EMedicare ID - Type Unspecified