Provider Demographics
NPI:1225238413
Name:KIDNEY AND HYPERTENSION CENTER OF IN, PC
Entity Type:Organization
Organization Name:KIDNEY AND HYPERTENSION CENTER OF IN, PC
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:PO BOX 2879
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-2879
Mailing Address - Country:US
Mailing Address - Phone:812-232-3900
Mailing Address - Fax:812-232-3955
Practice Address - Street 1:700 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IN
Practice Address - Zip Code:47842-2420
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:2007-07-25
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01052996A207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN224510Medicare PIN