Provider Demographics
NPI:1649574286
Name:COMPREHENSIVE KIDNEY DISEASE CENTER, LLC
Entity Type:Organization
Organization Name:COMPREHENSIVE KIDNEY DISEASE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:AMISH
Authorized Official - Middle Name:B
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-489-3007
Mailing Address - Street 1:333 WHITESPORT DR SW
Mailing Address - Street 2:SUITE 205
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-6454
Mailing Address - Country:US
Mailing Address - Phone:256-489-3007
Mailing Address - Fax:256-489-3045
Practice Address - Street 1:333 WHITESPORT DR SW
Practice Address - Street 2:SUITE 205
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-6454
Practice Address - Country:US
Practice Address - Phone:256-489-3007
Practice Address - Fax:256-489-3045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-22
Last Update Date:2011-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL25611207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
051519633SHAOtherMEDICARE ID TYPE UNSPECIFIED
ALH99272Medicare UPIN