Healthcare Provider Details

I. General information

NPI: 1134316680
Provider Name (Legal Business Name): CHILDRENS KIDNEY SPECIALISTS SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2007
Last Update Date: 01/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1954 1ST ST SUITE 200
HIGHLAND PARK IL
60035-3104
US

IV. Provider business mailing address

777 OAKMONT LN SUITE 1600
WESTMONT IL
60559-5511
US

V. Phone/Fax

Practice location:
  • Phone: 847-433-3345
  • Fax: 847-433-4426
Mailing address:
  • Phone: 630-789-2550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. RONALD J KALLEN
Title or Position: PRESIDENT OWNER
Credential: M.D.
Phone: 847-433-3345