Healthcare Provider Details

I. General information

NPI: 1255610440
Provider Name (Legal Business Name): NORTHWEST INDIANA RADIATION ONCOLOGY GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2011
Last Update Date: 11/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W 61ST AVE
HOBART IN
46342-6490
US

IV. Provider business mailing address

PO BOX 660408
INDIANAPOLIS IN
46266-0408
US

V. Phone/Fax

Practice location:
  • Phone: 219-942-5745
  • Fax: 219-462-7902
Mailing address:
  • Phone: 219-942-5745
  • Fax: 219-462-7902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: DR. KOPPOLU P SARMA
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 219-942-5745