Provider Demographics
NPI:1982642674
Name:KIDNEY SPECIALTY CLINIC P A
Entity Type:Organization
Organization Name:KIDNEY SPECIALTY CLINIC P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:JARDIEL
Authorized Official - Last Name:TALON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-300-1289
Mailing Address - Street 1:222 HIGH ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:NEWTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07860-9604
Mailing Address - Country:US
Mailing Address - Phone:973-300-1289
Mailing Address - Fax:973-300-9573
Practice Address - Street 1:222 HIGH ST
Practice Address - Street 2:SUITE 206
Practice Address - City:NEWTON
Practice Address - State:NJ
Practice Address - Zip Code:07860-9604
Practice Address - Country:US
Practice Address - Phone:973-300-1289
Practice Address - Fax:973-300-9573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
067618Medicare PIN