Provider Demographics
NPI:1629287792
Name:HOME DIALYSIS DULUTH KIDNEY SERVICES
Entity Type:Organization
Organization Name:HOME DIALYSIS DULUTH KIDNEY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:POPHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:218-249-6230
Mailing Address - Street 1:925 E SUPERIOR ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-2238
Mailing Address - Country:US
Mailing Address - Phone:218-249-6230
Mailing Address - Fax:218-249-6231
Practice Address - Street 1:925 E SUPERIOR ST
Practice Address - Street 2:SUITE 106
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-2238
Practice Address - Country:US
Practice Address - Phone:218-249-6230
Practice Address - Fax:218-249-6231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN35304207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty