Healthcare Provider Details

I. General information

NPI: 1225238413
Provider Name (Legal Business Name): KIDNEY AND HYPERTENSION CENTER OF IN, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2007
Last Update Date: 07/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 S MAIN ST
CLINTON IN
47842-2420
US

IV. Provider business mailing address

PO BOX 2879
INDIANAPOLIS IN
46206-2879
US

V. Phone/Fax

Practice location:
  • Phone: 812-232-3900
  • Fax: 812-232-3955
Mailing address:
  • Phone: 812-232-3900
  • Fax: 812-232-3955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number01052996A
License Number StateIN

VIII. Authorized Official

Name: SHERIF ELASSAL
Title or Position: OWNER
Credential: MD
Phone: 812-232-3900