Provider Demographics
NPI:1336259548
Name:MID DELTA KIDNEY CENTER
Entity Type:Organization
Organization Name:MID DELTA KIDNEY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NED
Authorized Official - Middle Name:
Authorized Official - Last Name:KRONFOL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-335-4105
Mailing Address - Street 1:1997 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38703-7268
Mailing Address - Country:US
Mailing Address - Phone:662-332-7100
Mailing Address - Fax:662-378-2879
Practice Address - Street 1:1997 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703-7268
Practice Address - Country:US
Practice Address - Phone:662-332-7100
Practice Address - Fax:662-378-2879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2008-06-28
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
MS0220419Medicaid
MS0220419Medicaid