Provider Demographics
NPI:1831822956
Name:KIDNEY CARE HOME SC
Entity type:Organization
Organization Name:KIDNEY CARE HOME SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GANESH
Authorized Official - Middle Name:N
Authorized Official - Last Name:PULLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-564-8636
Mailing Address - Street 1:6125 GREEN BAY RD STE 200
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-2945
Mailing Address - Country:US
Mailing Address - Phone:262-564-8636
Mailing Address - Fax:262-564-8637
Practice Address - Street 1:6125 GREEN BAY RD STE 200
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-2945
Practice Address - Country:US
Practice Address - Phone:262-564-8636
Practice Address - Fax:262-564-8637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-06
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32537500Medicaid