Provider Demographics
NPI:1629186168
Name:DALLAS RENAL GROUP PA
Entity Type:Organization
Organization Name:DALLAS RENAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:YUGANDHAR
Authorized Official - Middle Name:
Authorized Official - Last Name:CHIMATA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-274-5555
Mailing Address - Street 1:3571 W WHEATLAND RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75237-3461
Mailing Address - Country:US
Mailing Address - Phone:972-274-5555
Mailing Address - Fax:972-274-5663
Practice Address - Street 1:3571 W WHEATLAND RD
Practice Address - Street 2:SUITE 101
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237-3461
Practice Address - Country:US
Practice Address - Phone:972-274-5555
Practice Address - Fax:972-274-5663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL7332207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX173547401Medicaid
TX173547402Medicaid
TX173547401Medicaid