Provider Demographics
NPI:1770155830
Name:FLORIDA KIDNEY PHYSICIANS, LLC
Entity type:Organization
Organization Name:FLORIDA KIDNEY PHYSICIANS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:ELENA
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-610-6100
Mailing Address - Street 1:12662 TELECOM DR
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33637-0935
Mailing Address - Country:US
Mailing Address - Phone:813-910-0030
Mailing Address - Fax:813-971-6473
Practice Address - Street 1:2585 HERSCHEL ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4557
Practice Address - Country:US
Practice Address - Phone:904-388-2678
Practice Address - Fax:904-388-6776
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FLORIDA KIDNEY PHYSICIANS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-07-16
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty