MEDICARE: AUSTIN KIDNEY CARE 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	:	1841849098
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AUSTIN KIDNEY CARE LLC

Provider Business Mailing Address
First Line	:	2005 PALO DURO RD
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78757-3242
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2005 PALO DURO RD
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78757-3242
Country	:	US
Telephone Number	:	617-538-2245
Fax Number	:

Authorized Official
Title or Position	:	MD
Name	:	RAEEDA GHEEWALA
Credential	:
Telephone Number	:	617-538-2245

Provider Enumeration Date	:	09/10/2019
Last Update Date	:	09/10/2019

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