Provider Demographics
NPI:1821026477
Name:KIDNEY HYPERTENSION CENTER ,LLC
Entity Type:Organization
Organization Name:KIDNEY HYPERTENSION CENTER ,LLC
Other - Org Name:NONE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHIEF
Authorized Official - Prefix:DR
Authorized Official - First Name:RALUCA
Authorized Official - Middle Name:
Authorized Official - Last Name:COYLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-680-0400
Mailing Address - Street 1:733 BLOOMFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-2545
Mailing Address - Country:US
Mailing Address - Phone:973-680-0400
Mailing Address - Fax:973-680-0450
Practice Address - Street 1:733 BLOOMFIELD AVE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-2545
Practice Address - Country:US
Practice Address - Phone:973-680-0400
Practice Address - Fax:973-680-0450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-30
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07375100174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0019259Medicaid
NJG33984Medicare UPIN
NJ0019259Medicaid