Provider Demographics
NPI:1750829230
Name:ALTUS DIRECT, LLC
Entity Type:Organization
Organization Name:ALTUS DIRECT, LLC
Other - Org Name:SUPRO DIRECT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TIN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PRAVEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:RAJANAHALLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-300-7424
Mailing Address - Street 1:701 E COUNTY LINE RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-1072
Mailing Address - Country:US
Mailing Address - Phone:317-300-7424
Mailing Address - Fax:317-360-6245
Practice Address - Street 1:701 E COUNTY LINE RD
Practice Address - Street 2:SUITE 210
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-1072
Practice Address - Country:US
Practice Address - Phone:317-300-7424
Practice Address - Fax:317-360-7976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-06
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty