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General NPI Number Information
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NPI Number | 1992383319
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Entity Type | Organization
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Legal Business Name | MAIN STREET KIDNEY GROUP
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Dates
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Enumeration Date | 03/29/2021
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Last Update Date | 03/29/2021
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Provider Practice Location Address
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Address Line | 3 N MAIN ST
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City | FREEPORT
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State | NY
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Zip | 11520-2218
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Country | US
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Telephone | 516-623-5076
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 37216
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City | ELMONT
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State | NY
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Zip | 11003-7216
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Country | US
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Telephone | 516-623-5076
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Fax | 516-623-0312
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Authorized Official
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Title or Position | CEO
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Name | DR. IHEANYICHUKWU AJA-ONU
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Credential | MD
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Telephone | 516-623-5076
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RN0300X
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Taxonomy Name | Nephrology Physician
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License Number |
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License Number State |
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