Provider Demographics
NPI:1174675789
Name:KIDNEY AND HYPERTENSION CENTER OF IN
Entity Type:Organization
Organization Name:KIDNEY AND HYPERTENSION CENTER OF IN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHERIF
Authorized Official - Middle Name:
Authorized Official - Last Name:ELASSAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-232-3900
Mailing Address - Street 1:3740 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-5507
Mailing Address - Country:US
Mailing Address - Phone:812-232-3900
Mailing Address - Fax:812-232-3955
Practice Address - Street 1:2229 MARY SHERMAN DR
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:IN
Practice Address - Zip Code:47882-7633
Practice Address - Country:US
Practice Address - Phone:812-232-3900
Practice Address - Fax:812-232-3955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01052996207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN224510Medicare ID - Type UnspecifiedGROUP #