Provider Demographics
NPI:1205165602
Name:TRI-CITIES NEPHROLOGY, LLC
Entity type:Organization
Organization Name:TRI-CITIES NEPHROLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:RAND
Authorized Official - Middle Name:
Authorized Official - Last Name:WORTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-946-4611
Mailing Address - Street 1:945 GOETHALS DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-3552
Mailing Address - Country:US
Mailing Address - Phone:509-942-3627
Mailing Address - Fax:
Practice Address - Street 1:833 SWIFT BLVD
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3513
Practice Address - Country:US
Practice Address - Phone:509-942-3627
Practice Address - Fax:509-943-5922
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KADLEC HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-12-14
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00043231207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1205165602Medicaid
WA0258389OtherLABOR & INDUSTRIES
WAG8890005Medicare PIN