Provider Demographics
NPI:1790002756
Name:CHARLOTTE NEPHROLOGY ASSOCIATES, PA
Entity Type:Organization
Organization Name:CHARLOTTE NEPHROLOGY ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LALITA
Authorized Official - Middle Name:D
Authorized Official - Last Name:THATTE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-629-4676
Mailing Address - Street 1:3300 TAMIAMI TRL
Mailing Address - Street 2:#101A
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-8054
Mailing Address - Country:US
Mailing Address - Phone:941-629-4676
Mailing Address - Fax:941-629-1522
Practice Address - Street 1:15121 TAMIAMI TRL
Practice Address - Street 2:#A
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34287-2711
Practice Address - Country:US
Practice Address - Phone:941-629-4676
Practice Address - Fax:941-629-1522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-29
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL60708207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK0817Medicare UPIN