Provider Demographics
NPI:1669503967
Name:RENAL MEDICAL GROUP
Entity Type:Organization
Organization Name:RENAL MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:J
Authorized Official - Last Name:HALEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-625-4630
Mailing Address - Street 1:515 S LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93277-2616
Mailing Address - Country:US
Mailing Address - Phone:559-625-4630
Mailing Address - Fax:559-625-4699
Practice Address - Street 1:515 S LOCUST ST
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93277-2616
Practice Address - Country:US
Practice Address - Phone:559-625-4630
Practice Address - Fax:559-625-4699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========Medicaid
CAZZZ23004ZMedicare ID - Type Unspecified
CA1013078393Medicare UPIN