=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114035615
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHEAST NEPHROLOGY CONSULTANTS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2006
-----------------------------------------------------
Last Update Date | 08/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3100 THEODORE ST STE 201
-----------------------------------------------------
City | JOLIET
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60435-0605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-717-8750
-----------------------------------------------------
Fax | 815-717-8751
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3100 THEODORE STREET SUITE 201
-----------------------------------------------------
City | JOLIET
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-744-5550
-----------------------------------------------------
Fax | 815-744-5428
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SENIOR REVENUE CYCLE SUPERVISOR
-----------------------------------------------------
Name | KRISTIN L JOYCE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 331-216-1163
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number | 042.005614
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------