Provider Demographics
NPI:1669501912
Name:KIDNEY CARE SERVICES OF SOUTHERN ILLINOIS, LTD
Entity Type:Organization
Organization Name:KIDNEY CARE SERVICES OF SOUTHERN ILLINOIS, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:S
Authorized Official - Last Name:SHAFI
Authorized Official - Suffix:
Authorized Official - Credentials:MC
Authorized Official - Phone:618-542-3048
Mailing Address - Street 1:PO BOX 181
Mailing Address - Street 2:
Mailing Address - City:DU QUOIN
Mailing Address - State:IL
Mailing Address - Zip Code:62832-0181
Mailing Address - Country:US
Mailing Address - Phone:618-542-3048
Mailing Address - Fax:618-542-3097
Practice Address - Street 1:900 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:DU QUOIN
Practice Address - State:IL
Practice Address - Zip Code:62832-1230
Practice Address - Country:US
Practice Address - Phone:618-542-3048
Practice Address - Fax:618-542-3097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036102569261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036102569Medicaid
IL213020Medicare ID - Type UnspecifiedPROVIDER NUMBER
IL036102569Medicaid