MEDICARE: KIDNEY CARE CENTER NORTH TAMPA 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		FL

General Provider Information

NPI Number	:	1922479336
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDNEY CARE CENTER NORTH TAMPA LLC

Provider Business Mailing Address
First Line	:	PO BOX 3877
Second Line	:
City	:	JOLIET
State	:	IL
Zip	:	60434-3877
Country	:	US
Telephone Number	:	815-741-6830
Fax Number	:	815-741-6832

Provider Business Practice Location Address
First Line	:	7187 BROAD ST
Second Line	:
City	:	BROOKSVILLE
State	:	FL
Zip	:	34601-5536
Country	:	US
Telephone Number	:	815-741-6830
Fax Number	:	815-741-6832

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. MORUFU ALAUSA
Credential	:	M.D
Telephone Number	:	815-741-6830

Provider Enumeration Date	:	10/12/2015
Last Update Date	:	11/10/2015

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