Provider Demographics
NPI:1427025212
Name:BRANSON NEPHROLOGY LLC
Entity Type:Organization
Organization Name:BRANSON NEPHROLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:417-334-8288
Mailing Address - Street 1:PO BOX 429
Mailing Address - Street 2:
Mailing Address - City:BRANSON
Mailing Address - State:MO
Mailing Address - Zip Code:65615-0429
Mailing Address - Country:US
Mailing Address - Phone:417-334-8288
Mailing Address - Fax:417-334-6966
Practice Address - Street 1:101 SKAGGS RD
Practice Address - Street 2:SUITE 302
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-2075
Practice Address - Country:US
Practice Address - Phone:417-334-8288
Practice Address - Fax:417-334-6966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-01
Last Update Date:2010-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOCK7038OtherRAILROAD MEDICARE
AR1154352417Medicaid
AR1245268051Medicaid
AR149154002Medicaid
MO170362OtherBLUE CROSS MISSOURI
MO506052000Medicaid
AR1154352417Medicaid
AR149154002Medicaid