Healthcare Provider Details

I. General information

NPI: 1073961843
Provider Name (Legal Business Name): KIDNEY DOCTORS OF KENTUCKIANA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2016
Last Update Date: 10/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 WALL ST STE 103
JEFFERSONVILLE IN
47130-3695
US

IV. Provider business mailing address

PO BOX 950195
LOUISVILLE KY
40295-0195
US

V. Phone/Fax

Practice location:
  • Phone: 812-283-9111
  • Fax: 812-283-9001
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: MUAD A MAYA
Title or Position: OWNER
Credential: MD
Phone: 812-283-9111