Provider Demographics
NPI:1013064690
Name:IDAHO KIDNEY INSTITUTE LLP
Entity Type:Organization
Organization Name:IDAHO KIDNEY INSTITUTE LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FAHIM
Authorized Official - Middle Name:
Authorized Official - Last Name:RAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-904-4780
Mailing Address - Street 1:PO BOX 268934
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126-8934
Mailing Address - Country:US
Mailing Address - Phone:208-904-4780
Mailing Address - Fax:208-904-4832
Practice Address - Street 1:4511 ZEBE AVE
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-4707
Practice Address - Country:US
Practice Address - Phone:208-904-4780
Practice Address - Fax:208-904-4832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807177400Medicaid
ID807177400Medicaid