Provider Demographics
NPI:1780122366
Name:VALLEY KIDNEY SPECIALISTS, PC
Entity type:Organization
Organization Name:VALLEY KIDNEY SPECIALISTS, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAVINDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLLU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-432-4529
Mailing Address - Street 1:1230 S CEDAR CREST BLVD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-6367
Mailing Address - Country:US
Mailing Address - Phone:610-432-4529
Mailing Address - Fax:610-432-2206
Practice Address - Street 1:693 PORT CARBON SAINT CLAIR HWY
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-8604
Practice Address - Country:US
Practice Address - Phone:570-429-1432
Practice Address - Fax:570-429-1019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-03
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD044932E207RN0300X
PAMD021858E207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty