Provider Demographics
NPI:1306848569
Name:MODESTO KIDNEY MEDICAL GROUP
Entity Type:Organization
Organization Name:MODESTO KIDNEY MEDICAL GROUP
Other - Org Name:ITSARA AND LIU MD'S
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:D
Authorized Official - Last Name:MEISCHKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-706-9073
Mailing Address - Street 1:305 E GRANGER AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4345
Mailing Address - Country:US
Mailing Address - Phone:209-526-1606
Mailing Address - Fax:209-526-1677
Practice Address - Street 1:305 E GRANGER AVE
Practice Address - Street 2:STE 202
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4344
Practice Address - Country:US
Practice Address - Phone:209-526-1606
Practice Address - Fax:209-526-1677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-01
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA01031187 02207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0026660Medicaid
CAYYY49963YMedicare PIN