Provider Demographics
NPI:1093040719
Name:CANCER CARE CONSULTANTS, PC
Entity Type:Organization
Organization Name:CANCER CARE CONSULTANTS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BALAGOPAL
Authorized Official - Middle Name:
Authorized Official - Last Name:KERALAVARMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-742-4237
Mailing Address - Street 1:8554 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-7032
Mailing Address - Country:US
Mailing Address - Phone:219-750-9581
Mailing Address - Fax:219-750-9781
Practice Address - Street 1:8554 BROADWAY
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-7032
Practice Address - Country:US
Practice Address - Phone:219-750-9581
Practice Address - Fax:219-750-9781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-14
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01052677A207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL90001550OtherBSIL
IN201001720AMedicaid
IN201001720AMedicaid