Provider Demographics
NPI:1023380342
Name:SOTHLAKE CHILDREN'S CLINIC, LLC
Entity Type:Organization
Organization Name:SOTHLAKE CHILDREN'S CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SRIKIETR
Authorized Official - Middle Name:
Authorized Official - Last Name:DHANA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-738-1916
Mailing Address - Street 1:8300 BROADWAY
Mailing Address - Street 2:SUITE C
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-8602
Mailing Address - Country:US
Mailing Address - Phone:219-738-1916
Mailing Address - Fax:219-736-5685
Practice Address - Street 1:8300 BROADWAY
Practice Address - Street 2:SUITE C
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-8602
Practice Address - Country:US
Practice Address - Phone:219-738-1916
Practice Address - Fax:219-736-5685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-01
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01025756208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100360530AMedicaid