Provider Demographics
NPI:1861494049
Name:MOORTHI, KMLST (MD)
Entity Type:Individual
Prefix:DR
First Name:KMLST
Middle Name:
Last Name:MOORTHI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 W 22ND ST STE 200
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1563
Mailing Address - Country:US
Mailing Address - Phone:630-573-5000
Mailing Address - Fax:630-491-5472
Practice Address - Street 1:90 W 86TH AVE
Practice Address - Street 2:NEPHROLOGY ASSOCIATES OF NORTHERN INDIANA
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-7086
Practice Address - Country:US
Practice Address - Phone:219-791-1555
Practice Address - Fax:219-791-0679
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036106618207RN0300X
IN01063457A207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200876750Medicaid
INI22884Medicare UPIN
IN200876750Medicaid