Provider Demographics
NPI:1073961843
Name:KIDNEY DOCTORS OF KENTUCKIANA PLLC
Entity Type:Organization
Organization Name:KIDNEY DOCTORS OF KENTUCKIANA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MUAD
Authorized Official - Middle Name:A
Authorized Official - Last Name:MAYA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-283-9111
Mailing Address - Street 1:PO BOX 950195
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0195
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1035 WALL ST STE 103
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-3695
Practice Address - Country:US
Practice Address - Phone:812-283-9111
Practice Address - Fax:812-283-9001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-02
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201363590Medicaid
INDW6469OtherRAILROAD MEDICARE
KY7100419990Medicaid
KY50110029OtherPASSPORT HEALTH PLAN
IN201363590Medicaid
KYK203140Medicare PIN