Provider Demographics
NPI:1114035615
Name:NORTHEAST NEPHROLOGY CONSULTANTS
Entity Type:Organization
Organization Name:NORTHEAST NEPHROLOGY CONSULTANTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CONSTANCE
Authorized Official - Middle Name:L
Authorized Official - Last Name:FREDERICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-744-5550
Mailing Address - Street 1:3100 THEODORE STREET
Mailing Address - Street 2:SUITE 201
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435
Mailing Address - Country:US
Mailing Address - Phone:815-744-5550
Mailing Address - Fax:815-744-5428
Practice Address - Street 1:3100 THEODORE STREET
Practice Address - Street 2:SUITE 201
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435
Practice Address - Country:US
Practice Address - Phone:815-744-5550
Practice Address - Fax:815-744-5428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-26
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RN0300X
IL042.005614207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL797310Medicare PIN
IL727010Medicare PIN
IL727011Medicare PIN