Provider Demographics
NPI:1871609578
Name:KIDNEY SPECIALISTS OF THE PALM BEACHES LLC
Entity type:Organization
Organization Name:KIDNEY SPECIALISTS OF THE PALM BEACHES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MOHAN
Authorized Official - Middle Name:ISAAC
Authorized Official - Last Name:ABRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-868-4846
Mailing Address - Street 1:11301 OKEECHOBEE BLVD
Mailing Address - Street 2:SUITE 5A
Mailing Address - City:ROYAL PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411
Mailing Address - Country:US
Mailing Address - Phone:561-283-0384
Mailing Address - Fax:561-282-3238
Practice Address - Street 1:11301 OKEECHOBEE BLVD
Practice Address - Street 2:SUITE 5A
Practice Address - City:ROYAL PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411
Practice Address - Country:US
Practice Address - Phone:561-283-0384
Practice Address - Fax:561-282-3238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME83538173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL271936300Medicaid
FL94755OtherBLUE CROSS BLUE SHIELD
FL271936300Medicaid