Provider Demographics
NPI:1750575015
Name:MIDWEST KIDNEY CARE, LLC
Entity type:Organization
Organization Name:MIDWEST KIDNEY CARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:V
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-762-2020
Mailing Address - Street 1:111 ANN STREET
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-5163
Mailing Address - Country:US
Mailing Address - Phone:262-542-6179
Mailing Address - Fax:262-542-6182
Practice Address - Street 1:111 ANN STREET
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-5163
Practice Address - Country:US
Practice Address - Phone:262-542-6179
Practice Address - Fax:262-542-6182
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-30
Last Update Date:2011-10-27
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
WI100005874Medicaid
WI100005874Medicaid