Provider Demographics
NPI:1871918615
Name:KIDNEY CARE PA
Entity type:Organization
Organization Name:KIDNEY CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:SIMON
Authorized Official - Middle Name:V
Authorized Official - Last Name:SEGUN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-996-2727
Mailing Address - Street 1:PO BOX 373
Mailing Address - Street 2:
Mailing Address - City:SHORT HILLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07078-2152
Mailing Address - Country:US
Mailing Address - Phone:973-373-0903
Mailing Address - Fax:973-373-1087
Practice Address - Street 1:2130 MILLBURN AVE
Practice Address - Street 2:SUITE C3
Practice Address - City:MAPLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07040-3725
Practice Address - Country:US
Practice Address - Phone:973-996-2727
Practice Address - Fax:973-763-2558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-04
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08683000207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1194956490OtherINDIVIDUAL NPI