Provider Demographics
NPI:1720528383
Name:INDIANA CANCER SPECIALISTS, LLC
Entity Type:Organization
Organization Name:INDIANA CANCER SPECIALISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SRIDHAR
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-228-3393
Mailing Address - Street 1:8301 HARCOURT RD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-2081
Mailing Address - Country:US
Mailing Address - Phone:317-228-3393
Mailing Address - Fax:317-876-1305
Practice Address - Street 1:1907 W SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46901-5148
Practice Address - Country:US
Practice Address - Phone:765-456-5687
Practice Address - Fax:765-456-5811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-01
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies