Provider Demographics
NPI:1326314295
Name:ST PETERSBURG KIDNEY CARE LLC
Entity Type:Organization
Organization Name:ST PETERSBURG KIDNEY CARE LLC
Other - Org Name:ST. PETERSBURG KIDNEY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF NURSING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:BRADY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-371-7878
Mailing Address - Street 1:800 3RD AVE S
Mailing Address - Street 2:WEBB PLAZA
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4010
Mailing Address - Country:US
Mailing Address - Phone:727-821-3201
Mailing Address - Fax:727-821-3140
Practice Address - Street 1:800 3RD AVE S
Practice Address - Street 2:WEBB PLAZA
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4010
Practice Address - Country:US
Practice Address - Phone:727-821-3201
Practice Address - Fax:727-821-3140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-26
Last Update Date:2023-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006736000Medicaid
FL682522Medicare Oscar/Certification