MEDICARE: FLORIDA KIDNEY PHYSICIANS, LLC

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

General Provider Information

NPI Number	:	1598338485
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FLORIDA KIDNEY PHYSICIANS, LLC

Provider Business Mailing Address
First Line	:	905 BEACH BLVD STE B
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32250-4303
Country	:	US
Telephone Number	:	904-388-2678
Fax Number	:	904-388-6776

Provider Business Practice Location Address
First Line	:	905 BEACH BLVD STE B
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32250-4303
Country	:	US
Telephone Number	:	904-388-2678
Fax Number	:	904-388-6776

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	MARIA ELENA RIVERA
Credential	:
Telephone Number	:	480-610-6100

Provider Enumeration Date	:	07/20/2021
Last Update Date	:	07/20/2021

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