Provider Demographics
NPI:1598788994
Name:CENTRAL ILLINOIS KIDNEY & DIALYSIS ASSOCIATES, SC
Entity Type:Organization
Organization Name:CENTRAL ILLINOIS KIDNEY & DIALYSIS ASSOCIATES, SC
Other - Org Name:CENTRAL ILLINOIS KIDNEY & DIALYSIS
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SKINNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-726-0967
Mailing Address - Street 1:3401 CONIFER DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711-8300
Mailing Address - Country:US
Mailing Address - Phone:217-726-0967
Mailing Address - Fax:217-726-7633
Practice Address - Street 1:3401 CONIFER DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62711-8300
Practice Address - Country:US
Practice Address - Phone:217-726-0967
Practice Address - Fax:217-726-7633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042005163207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
31664OtherGHP GROUP PROVIDER NUMBER
8415035OtherBLUE CROSS BLUE SHIELD NU
31664OtherGHP GROUP PROVIDER NUMBER
8415035OtherBLUE CROSS BLUE SHIELD NU