Provider Demographics
NPI:1528480365
Name:COMORIN KIDNEYCARE PLLC
Entity type:Organization
Organization Name:COMORIN KIDNEYCARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:GREENWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-221-5152
Mailing Address - Street 1:PO BOX 510052
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48151-6052
Mailing Address - Country:US
Mailing Address - Phone:734-288-3370
Mailing Address - Fax:734-785-8421
Practice Address - Street 1:14555 LEVAN ROAD
Practice Address - Street 2:SUITE 308
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-6052
Practice Address - Country:US
Practice Address - Phone:734-288-3370
Practice Address - Fax:734-785-8421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-14
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301084038207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301084038Medicaid