Provider Demographics
NPI:1710115548
Name:UPPER VALLEY KIDNEY CLINIC
Entity Type:Organization
Organization Name:UPPER VALLEY KIDNEY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETER
Authorized Official - Prefix:
Authorized Official - First Name:NAVEED
Authorized Official - Middle Name:UL
Authorized Official - Last Name:HAQ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-335-9633
Mailing Address - Street 1:3130 N DIXIE HWY
Mailing Address - Street 2:STE 101
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-1337
Mailing Address - Country:US
Mailing Address - Phone:937-335-9633
Mailing Address - Fax:937-335-9464
Practice Address - Street 1:1266 N BROAD ST
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-5549
Practice Address - Country:US
Practice Address - Phone:937-879-0433
Practice Address - Fax:937-879-0589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-01
Last Update Date:2009-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35080974207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH60302Medicare UPIN