Provider Demographics
NPI:1205013653
Name:JETTY HEART CLINIC
Entity Type:Organization
Organization Name:JETTY HEART CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PREETHAM
Authorized Official - Middle Name:
Authorized Official - Last Name:JETTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-298-4422
Mailing Address - Street 1:1210 B MEDICAL ARTS BOULEVARD
Mailing Address - Street 2:SUITE 217
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46011-3439
Mailing Address - Country:US
Mailing Address - Phone:765-298-4422
Mailing Address - Fax:765-298-4926
Practice Address - Street 1:1210 B MEDICAL ARTS BOULEVARD
Practice Address - Street 2:SUITE 217
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46011-3439
Practice Address - Country:US
Practice Address - Phone:765-298-4422
Practice Address - Fax:765-298-4926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-29
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040154A207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200886890Medicaid
IN257870Medicare PIN