Provider Demographics
NPI:1942257019
Name:KOPPOLU P SARMA MD INC
Entity Type:Organization
Organization Name:KOPPOLU P SARMA MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KOPPOLU
Authorized Official - Middle Name:P
Authorized Official - Last Name:SARMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-942-5745
Mailing Address - Street 1:DEPT 6076
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60122
Mailing Address - Country:US
Mailing Address - Phone:219-942-5745
Mailing Address - Fax:
Practice Address - Street 1:300 W 61ST AVE
Practice Address - Street 2:CENTER FOR IMAGING AND RADIATION
Practice Address - City:HOBART
Practice Address - State:IN
Practice Address - Zip Code:46342-6490
Practice Address - Country:US
Practice Address - Phone:219-942-5745
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01027669A2085R0001X
2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100213740AMedicaid
IN200008710AMedicaid
IN200008710AMedicaid
IN706170Medicare PIN