Provider Demographics
NPI:1568466506
Name:KIDNEY TREATMENT CENTER NORTHWEST P A
Entity Type:Organization
Organization Name:KIDNEY TREATMENT CENTER NORTHWEST P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:J
Authorized Official - Last Name:MEDOLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-692-1515
Mailing Address - Street 1:3939 MEDICAL DR
Mailing Address - Street 2:STE 110
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-2292
Mailing Address - Country:US
Mailing Address - Phone:210-692-1515
Mailing Address - Fax:210-692-0187
Practice Address - Street 1:3939 MEDICAL DR
Practice Address - Street 2:STE 110
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-2292
Practice Address - Country:US
Practice Address - Phone:210-692-3075
Practice Address - Fax:210-692-0187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-08
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX007316261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1452880-02Medicaid
TX0943250-02Medicaid
TXHH6407OtherBCBS
TX1452880-02Medicaid
TX0943250-02Medicaid