Provider Demographics
NPI:1629010228
Name:KIDNEY SPECIALISTS OF MINNESOTA, PA
Entity Type:Organization
Organization Name:KIDNEY SPECIALISTS OF MINNESOTA, PA
Other - Org Name:KIDNEY DISEASE & CRITICAL CARE ASSOC., PA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:763-544-0696
Mailing Address - Street 1:6200 SHINGLE CREEK PKWY
Mailing Address - Street 2:SUITE 260
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55430-2128
Mailing Address - Country:US
Mailing Address - Phone:763-561-5349
Mailing Address - Fax:
Practice Address - Street 1:6200 SHINGLE CREEK PKWY
Practice Address - Street 2:SUITE 260
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55430-2128
Practice Address - Country:US
Practice Address - Phone:763-561-5349
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN3100002OtherMEDICA PRIMARY
SD7764930Medicaid
MN879710200Medicaid
OH2109926Medicaid
MNCP7137OtherRAILROAD MEDICARE
ND16530Medicaid
WI32722000Medicaid
MN361OtherHEALTHPARTNERS
MN12416KIOtherBCBSMN
IL279363181Medicaid
MNC01015OtherWPS MEDICARE
OH2109926Medicaid
SD7764930Medicaid