Provider Demographics
NPI:1467736561
Name:SERENITY MEDICAL CENTER WEST LLC
Entity Type:Organization
Organization Name:SERENITY MEDICAL CENTER WEST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:SYED
Authorized Official - Middle Name:J
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-621-4170
Mailing Address - Street 1:10765 LANTERN ROAD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-3597
Mailing Address - Country:US
Mailing Address - Phone:317-621-4170
Mailing Address - Fax:317-621-4182
Practice Address - Street 1:10765 LANTERN ROAD
Practice Address - Street 2:SUITE 202
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46038-3597
Practice Address - Country:US
Practice Address - Phone:317-621-4170
Practice Address - Fax:317-621-4182
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-06
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM100059426Medicare PIN