Healthcare Provider Details

I. General information

NPI: 1477680205
Provider Name (Legal Business Name): KIDNEY SPECIALISTS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 02/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 EASTMORELAND AVE SUITE 335
MEMPHIS TN
38104-3519
US

IV. Provider business mailing address

1325 EASTMORELAND AVE SUITE 335
MEMPHIS TN
38104-3519
US

V. Phone/Fax

Practice location:
  • Phone: 901-726-1199
  • Fax: 901-729-0794
Mailing address:
  • Phone: 901-726-1199
  • Fax: 901-729-0794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD0000026012
License Number StateTN

VIII. Authorized Official

Name: NAWAR E MANSOUR
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 901-729-1199