Provider Demographics
NPI:1932587300
Name:HOPKINSVILLE KIDNEY CARE PLLC
Entity Type:Organization
Organization Name:HOPKINSVILLE KIDNEY CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WALCZYK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-889-0282
Mailing Address - Street 1:215 BURLEY AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42240-8725
Mailing Address - Country:US
Mailing Address - Phone:270-889-0282
Mailing Address - Fax:602-798-8267
Practice Address - Street 1:215 BURLEY AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-8725
Practice Address - Country:US
Practice Address - Phone:270-889-0282
Practice Address - Fax:602-798-8267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-18
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RN0300X
KY41787207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100455650Medicaid