Provider Demographics
NPI:1609098003
Name:RENAL MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:RENAL MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAMIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:KHWAJA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-638-0533
Mailing Address - Street 1:3625 E MARTIN LUTHER KING JR BLVD #2
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262
Mailing Address - Country:US
Mailing Address - Phone:310-638-0533
Mailing Address - Fax:
Practice Address - Street 1:3625 E MARTIN LUTHER KING JR BLVD #2
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262
Practice Address - Country:US
Practice Address - Phone:310-638-0533
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0067120Medicaid
CAGR0067120Medicaid