Provider Demographics
NPI:1164645511
Name:SPACE CITY ASSOCIATES OF NEPHROLOGY
Entity Type:Organization
Organization Name:SPACE CITY ASSOCIATES OF NEPHROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MAHENDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:AGRAHARKAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-554-5445
Mailing Address - Street 1:2301 CARINA CT
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-2879
Mailing Address - Country:US
Mailing Address - Phone:281-554-5445
Mailing Address - Fax:281-554-5445
Practice Address - Street 1:212 GULF FWY S
Practice Address - Street 2:SUITE G3
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-3524
Practice Address - Country:US
Practice Address - Phone:281-316-1763
Practice Address - Fax:281-316-1385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2008-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX193620501Medicaid
TX00X942Medicare PIN