Healthcare Provider Details

I. General information

NPI: 1811437460
Provider Name (Legal Business Name): INDIANA CANCER SPECIALISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2017
Last Update Date: 03/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 RONALD REAGAN PKWY SUITE B1500
AVON IN
46123-7085
US

IV. Provider business mailing address

8301 HARCOURT RD SUITE 205
INDIANAPOLIS IN
46260-2081
US

V. Phone/Fax

Practice location:
  • Phone: 317-217-2244
  • Fax: 317-217-2240
Mailing address:
  • Phone: 317-228-3393
  • Fax: 317-876-1305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: SRIDHAR BOLLA
Title or Position: PRESIDENT
Credential: MD
Phone: 317-228-3393