Provider Demographics
NPI:1972833267
Name:ADDISON KIDNEY CONSULTING PLLC
Entity type:Organization
Organization Name:ADDISON KIDNEY CONSULTING PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:F
Authorized Official - Last Name:ADDISON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-205-7790
Mailing Address - Street 1:331 LAIDLEY ST STE 204
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1605
Mailing Address - Country:US
Mailing Address - Phone:304-205-7790
Mailing Address - Fax:304-205-7792
Practice Address - Street 1:331 LAIDLEY ST
Practice Address - Street 2:SUITE 307
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1619
Practice Address - Country:US
Practice Address - Phone:304-208-1414
Practice Address - Fax:304-344-2108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-08
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV15775207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty