Provider Demographics
NPI:1518969765
Name:PENSACOLA NEPHROLOGY PA
Entity Type:Organization
Organization Name:PENSACOLA NEPHROLOGY PA
Other - Org Name:RENALUS CENTER FOR KIDNEY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATION
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHANTELLE
Authorized Official - Middle Name:S
Authorized Official - Last Name:ROS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-444-4700
Mailing Address - Street 1:PO BOX 11037
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32524-1037
Mailing Address - Country:US
Mailing Address - Phone:850-444-4700
Mailing Address - Fax:850-444-7497
Practice Address - Street 1:1619 CREIGHTON RD STE 1
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-7152
Practice Address - Country:US
Practice Address - Phone:850-444-4700
Practice Address - Fax:850-434-8144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCF9776OtherRRB PTAN
FL256870500Medicaid
FL256870509Medicaid
FL256870512Medicaid
FL256870510Medicaid
FL256870513Medicaid
ALCF9777OtherRRB PTAN
FLCF9776OtherRRB PTAN
FL256870510Medicaid
ALH796OtherMEDICARE ALABAMA
FL256870508Medicaid
FL256870504Medicaid
FL256870506Medicaid
FL256870502Medicaid
FLCF9776OtherRRB PTAN
FLK1167BMedicare PIN