MEDICARE: NEPHROLOGY CLINIC PC

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	:	1942297742
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEPHROLOGY CLINIC PC

Provider Business Mailing Address
First Line	:	3351 EASTBROOK DR STE 100
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-5744
Country	:	US
Telephone Number	:	970-493-7733
Fax Number	:	970-493-8745

Provider Business Practice Location Address
First Line	:	3351 EASTBROOK DR STE 100
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-5744
Country	:	US
Telephone Number	:	970-493-7733
Fax Number	:	970-493-8745

Authorized Official
Title or Position	:	PRACTICE ADMINISTRATOR
Name	:	TOBEY MIKULA
Credential	:
Telephone Number	:	970-493-7733

Provider Enumeration Date	:	10/05/2005
Last Update Date	:	03/20/2023

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