Provider Demographics
NPI:1013665488
Name:INTEGRATIVE KIDNEY ASSOCIATES, PLLC
Entity type:Organization
Organization Name:INTEGRATIVE KIDNEY ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:KALILIAH
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-287-3212
Mailing Address - Street 1:421 S SHARON AMITY RD STE B
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-2882
Mailing Address - Country:US
Mailing Address - Phone:704-826-3722
Mailing Address - Fax:404-506-9090
Practice Address - Street 1:421 S SHARON AMITY RD STE B
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-2882
Practice Address - Country:US
Practice Address - Phone:704-826-3722
Practice Address - Fax:404-506-9090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-15
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5911907Medicaid