MEDICARE: WICHITA FALLS KIDNEY CLINIC 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	207R00000X	Internal Medicine Physician
2	207RN0300X	Nephrology Physician

General Provider Information

NPI Number	:	1598064552
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WICHITA FALLS KIDNEY CLINIC PA

Provider Business Mailing Address
First Line	:	1508 10TH ST
Second Line	:
City	:	WICHITA FALLS
State	:	TX
Zip	:	76301-4401
Country	:	US
Telephone Number	:	940-263-1286
Fax Number	:

Provider Business Practice Location Address
First Line	:	1508 10TH ST
Second Line	:
City	:	WICHITA FALLS
State	:	TX
Zip	:	76301-4401
Country	:	US
Telephone Number	:	940-263-1286
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JAYASANKAR KALUVAPELLE REDDY
Credential	:	M.D.
Telephone Number	:	512-777-9650

Provider Enumeration Date	:	03/16/2011
Last Update Date	:	12/20/2012

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