Provider Demographics
NPI:1891866380
Name:KIDNEY INSTITUTE OF WISCONSIN, LLC
Entity Type:Organization
Organization Name:KIDNEY INSTITUTE OF WISCONSIN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:HERBERT
Authorized Official - Middle Name:S
Authorized Official - Last Name:LAWSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-785-7521
Mailing Address - Street 1:2100 CENTRAL AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-2838
Mailing Address - Country:US
Mailing Address - Phone:303-785-7523
Mailing Address - Fax:303-444-8639
Practice Address - Street 1:10130 W APPLETON AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53225-2579
Practice Address - Country:US
Practice Address - Phone:414-393-0600
Practice Address - Fax:414-393-0910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42058900Medicaid
WI42058900Medicaid
WI522548Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER