MEDICARE: SPACE CITY ASSOCIATES OF NEPHROLOGY, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RN0300X	Nephrology Physician		TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164645511
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPACE CITY ASSOCIATES OF NEPHROLOGY, PA

Provider Business Mailing Address
First Line	:	2301 CARINA CT
Second Line	:
City	:	LEAGUE CITY
State	:	TX
Zip	:	77573-2879
Country	:	US
Telephone Number	:	281-554-5445
Fax Number	:	281-554-5445

Provider Business Practice Location Address
First Line	:	560 BLOSSOM ST STE C
Second Line	:
City	:	WEBSTER
State	:	TX
Zip	:	77598-4237
Country	:	US
Telephone Number	:	832-905-6141
Fax Number	:	832-200-3259

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. MAHENDRA AGRAHARKAR
Credential	:	M.D.
Telephone Number	:	832-905-6141

Provider Enumeration Date	:	04/11/2007
Last Update Date	:	02/05/2025

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