Provider Demographics
NPI:1013962729
Name:VALLEY KIDNEY CENTER INC
Entity Type:Organization
Organization Name:VALLEY KIDNEY CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BAHADUR
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-564-0047
Mailing Address - Street 1:5150 N 16TH ST
Mailing Address - Street 2:STE B232
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-3990
Mailing Address - Country:US
Mailing Address - Phone:623-977-1331
Mailing Address - Fax:623-977-1449
Practice Address - Street 1:13943 N 91ST AVE
Practice Address - Street 2:STE H101
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-3689
Practice Address - Country:US
Practice Address - Phone:623-977-1331
Practice Address - Fax:623-977-1449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ333266Medicaid
AZH20971Medicare UPIN
AZZ70546Medicare PIN