Provider Demographics
NPI:1598824492
Name:MIDWEST NEPHROLOGY GROUP, LLC
Entity Type:Organization
Organization Name:MIDWEST NEPHROLOGY GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTORE
Authorized Official - Prefix:
Authorized Official - First Name:VENKATESWARARAO
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-284-0555
Mailing Address - Street 1:101 WEST 2ND STREET
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-3053
Mailing Address - Country:US
Mailing Address - Phone:815-284-0555
Mailing Address - Fax:815-284-0580
Practice Address - Street 1:101 WEST 2ND STREET
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-3053
Practice Address - Country:US
Practice Address - Phone:815-284-0555
Practice Address - Fax:815-284-0580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036056049Medicaid
IL05232009OtherBCBS
IL036114547Medicaid
IL036103114Medicaid
IL036114547Medicaid
G64184Medicare UPIN
209482Medicare ID - Type Unspecified