Provider Demographics
NPI:1669651105
Name:KRISHNAN POTTI, M.D.
Entity Type:Organization
Organization Name:KRISHNAN POTTI, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:THERESE
Authorized Official - Middle Name:A
Authorized Official - Last Name:HINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-769-4616
Mailing Address - Street 1:8300 BROADWAY STE B
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-8602
Mailing Address - Country:US
Mailing Address - Phone:219-769-4616
Mailing Address - Fax:219-736-0719
Practice Address - Street 1:8300 BROADWAY STE B
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-8602
Practice Address - Country:US
Practice Address - Phone:219-769-4616
Practice Address - Fax:219-736-0719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-01
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01025043A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
457150Medicare PIN
INE86130Medicare UPIN