Provider Demographics
NPI:1598003220
Name:CLINICAL NEPHROLOGY ASSOCIATES, PA
Entity Type:Organization
Organization Name:CLINICAL NEPHROLOGY ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:GRATCH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:817-923-8050
Mailing Address - Street 1:PO BOX 470787
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76147-0787
Mailing Address - Country:US
Mailing Address - Phone:817-923-8050
Mailing Address - Fax:817-923-8832
Practice Address - Street 1:11797 SOUTH FWY
Practice Address - Street 2:SUITE 226
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-7026
Practice Address - Country:US
Practice Address - Phone:817-923-8050
Practice Address - Fax:817-923-8832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-31
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF8496207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX085155204Medicaid
TXT0017ZMedicare PIN