Healthcare Provider Details

I. General information

NPI: 1124287180
Provider Name (Legal Business Name): NEPHROLOGY AND HYPERTENSION CONSULTANTS SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2008
Last Update Date: 11/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1480 RENAISSANCE DR SUITE 211
PARK RIDGE IL
60068-1332
US

IV. Provider business mailing address

1480 RENAISSANCE DR SUITE 211
PARK RIDGE IL
60068-1332
US

V. Phone/Fax

Practice location:
  • Phone: 813-890-8004
  • Fax: 813-290-9691
Mailing address:
  • Phone: 813-890-8004
  • Fax: 813-290-9691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number036051280
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number036051280
License Number StateIL

VIII. Authorized Official

Name: KENNETH MILLER
Title or Position: PHYSICIAN/OWNER
Credential: MD
Phone: 813-890-8004