Provider Demographics
NPI:1518016773
Name:KIDNEY CENTER A MEDICAL GROUP INC
Entity Type:Organization
Organization Name:KIDNEY CENTER A MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:CAROLINE
Authorized Official - Middle Name:
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:661-869-2600
Mailing Address - Street 1:PO BOX 11959
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93389-3959
Mailing Address - Country:US
Mailing Address - Phone:661-869-2600
Mailing Address - Fax:661-869-2003
Practice Address - Street 1:3543 SAN DIMAS ST
Practice Address - Street 2:SUITE B
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93301-1605
Practice Address - Country:US
Practice Address - Phone:661-869-2600
Practice Address - Fax:661-869-2003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG75701207RN0300X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ04314ZMedicaid
CAZZZ04314ZMedicare PIN
CAF65815Medicare UPIN
CAZZZ04314ZMedicaid