Provider Demographics
NPI:1952589665
Name:ANGELO KIDNEY CONNECTION, PLLC
Entity Type:Organization
Organization Name:ANGELO KIDNEY CONNECTION, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:BAUMGARTNER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:325-617-2496
Mailing Address - Street 1:P.O. BOX 61074
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76906-1074
Mailing Address - Country:US
Mailing Address - Phone:325-617-2496
Mailing Address - Fax:325-617-2497
Practice Address - Street 1:2901 SHERWOOD WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76901-3586
Practice Address - Country:US
Practice Address - Phone:326-617-2496
Practice Address - Fax:325-617-2497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-05
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QE0700X
TX8643261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1948945Medicaid
TX1948945Medicaid