Provider Demographics
NPI:1609856640
Name:WESTERN ILLINOIS KIDNEY CENTER
Entity Type:Organization
Organization Name:WESTERN ILLINOIS KIDNEY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO & MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PARTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:SRINIVASAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-345-4580
Mailing Address - Street 1:765 N KELLOGG ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-2875
Mailing Address - Country:US
Mailing Address - Phone:309-345-4580
Mailing Address - Fax:309-345-4581
Practice Address - Street 1:765 N KELLOGG ST
Practice Address - Street 2:SUITE 101
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-2875
Practice Address - Country:US
Practice Address - Phone:309-345-4580
Practice Address - Fax:309-345-4581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL001261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL142579Medicare ID - Type Unspecified