Provider Demographics
NPI:1609982214
Name:KIDNEY DISEASE CONSULTANTS OF BRADENTON PA
Entity type:Organization
Organization Name:KIDNEY DISEASE CONSULTANTS OF BRADENTON PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:NEWBY
Authorized Official - Last Name:BRAXTAN
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:941-744-0024
Mailing Address - Street 1:508 MANATEE AVE E
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34208-1146
Mailing Address - Country:US
Mailing Address - Phone:941-744-0024
Mailing Address - Fax:941-746-1048
Practice Address - Street 1:508 MANATEE AVE E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-1146
Practice Address - Country:US
Practice Address - Phone:941-744-0024
Practice Address - Fax:941-746-1048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCE7954OtherRAILROAD MEDICARE
FL39285Medicare ID - Type Unspecified