Provider Demographics
NPI:1780842641
Name:COLONIAL KIDNEY SPECIALISTS PLLC
Entity Type:Organization
Organization Name:COLONIAL KIDNEY SPECIALISTS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SATISH
Authorized Official - Middle Name:K
Authorized Official - Last Name:BANKURU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-504-0068
Mailing Address - Street 1:3601 BOULVARD
Mailing Address - Street 2:SUITE C
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-1338
Mailing Address - Country:US
Mailing Address - Phone:804-504-0068
Mailing Address - Fax:804-504-0080
Practice Address - Street 1:3601 BOULVARD
Practice Address - Street 2:SUITE C
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-1338
Practice Address - Country:US
Practice Address - Phone:804-504-0068
Practice Address - Fax:804-504-0080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-28
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101236668207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAMC10242Medicare PIN
VAGC1009Medicare PIN