Provider Demographics
NPI:1801248356
Name:CAPITAL NEPHROLOGY CLINIC, P.A.
Entity type:Organization
Organization Name:CAPITAL NEPHROLOGY CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RITA
Authorized Official - Middle Name:F
Authorized Official - Last Name:HOFFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-444-4700
Mailing Address - Street 1:1845 JACLIF CT
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4430
Mailing Address - Country:US
Mailing Address - Phone:850-999-2328
Mailing Address - Fax:850-320-6114
Practice Address - Street 1:1845 JACLIF CT
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308
Practice Address - Country:US
Practice Address - Phone:850-999-2328
Practice Address - Fax:850-320-6114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-08
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME113752207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018119800Medicaid
FLME113752OtherFLORIDA MEDICAL LICENSE