Provider Demographics
NPI:1467672261
Name:KIDNEY CARE PHYSICIANS LLC
Entity Type:Organization
Organization Name:KIDNEY CARE PHYSICIANS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:EVAL
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-561-8565
Mailing Address - Street 1:875 OAK ST SE STE 5070
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3975
Mailing Address - Country:US
Mailing Address - Phone:503-561-8565
Mailing Address - Fax:503-561-8560
Practice Address - Street 1:875 OAK ST SE STE 5070
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3975
Practice Address - Country:US
Practice Address - Phone:503-561-8565
Practice Address - Fax:503-561-8560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11594223207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR100101Medicaid
OR100101Medicaid