Provider Demographics
NPI:1700855228
Name:MID-ATLANTIC KIDNEY CENTER
Entity Type:Organization
Organization Name:MID-ATLANTIC KIDNEY CENTER
Other - Org Name:MID-ATLANTIC NEPHROLOGY ASSOCIATES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:S
Authorized Official - Last Name:MOODY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-643-3061
Mailing Address - Street 1:2201 E MAIN ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23223-7071
Mailing Address - Country:US
Mailing Address - Phone:804-643-3061
Mailing Address - Fax:804-643-3817
Practice Address - Street 1:2201 E MAIN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223-7071
Practice Address - Country:US
Practice Address - Phone:804-643-3061
Practice Address - Fax:804-643-3817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-16
Last Update Date:2009-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty