Provider Demographics
NPI:1073582714
Name:EASTERN PA NEPHROLOGY ASSOC P.C.
Entity Type:Organization
Organization Name:EASTERN PA NEPHROLOGY ASSOC P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAVINDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLLU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-432-4529
Mailing Address - Street 1:1230 S CEDAR CREST BLVD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-6212
Mailing Address - Country:US
Mailing Address - Phone:610-432-4529
Mailing Address - Fax:610-432-2206
Practice Address - Street 1:1230 S CEDAR CREST BLVD
Practice Address - Street 2:SUITE 301
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-6212
Practice Address - Country:US
Practice Address - Phone:610-432-4529
Practice Address - Fax:610-432-2206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-15
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CB0122OtherRR MEDICARE
PA1003633Medicaid
PA060332Medicare ID - Type UnspecifiedGROUP NUMBER