Provider Demographics
NPI:1669798823
Name:MOHAVE NEPHROLOGY,PC
Entity type:Organization
Organization Name:MOHAVE NEPHROLOGY,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:VIJAYAVEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PALANICHAMY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-757-2050
Mailing Address - Street 1:3535 E ANDY DEVINE AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-3412
Mailing Address - Country:US
Mailing Address - Phone:928-757-2050
Mailing Address - Fax:928-757-2020
Practice Address - Street 1:3535 E ANDY DEVINE AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-3412
Practice Address - Country:US
Practice Address - Phone:928-757-2050
Practice Address - Fax:928-757-2020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-13
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ27022207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ442682-02Medicaid
AZ29876Medicare PIN
AZ442682-02Medicaid