Provider Demographics
NPI:1851749386
Name:PITTSBURGH KIDNEY CARE, LLC
Entity Type:Organization
Organization Name:PITTSBURGH KIDNEY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WALCZYK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:412-621-3631
Mailing Address - Street 1:1401 FORBES AVE
Mailing Address - Street 2:350
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15219-5125
Mailing Address - Country:US
Mailing Address - Phone:412-621-3631
Mailing Address - Fax:412-687-2394
Practice Address - Street 1:1401 FORBES AVE
Practice Address - Street 2:350
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15219-5125
Practice Address - Country:US
Practice Address - Phone:412-621-3631
Practice Address - Fax:412-687-2394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-25
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0001632207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103217936 0001Medicaid
PA514321Medicare PIN