Provider Demographics
NPI:1427509751
Name:MEDICINE AND NEPHROLOGY CLINIC LLC
Entity type:Organization
Organization Name:MEDICINE AND NEPHROLOGY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NDUBUEZE
Authorized Official - Middle Name:FIDELIS
Authorized Official - Last Name:OKONKWO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:316-452-5455
Mailing Address - Street 1:700 W CENTRAL AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:KS
Mailing Address - Zip Code:67042-2186
Mailing Address - Country:US
Mailing Address - Phone:316-452-5455
Mailing Address - Fax:316-321-0503
Practice Address - Street 1:700 W CENTRAL AVE STE 206
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:KS
Practice Address - Zip Code:67042-2186
Practice Address - Country:US
Practice Address - Phone:316-452-5455
Practice Address - Fax:316-321-0503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-21
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1972118Medicaid
LA1972118Medicaid