Healthcare Provider Details

I. General information

NPI: 1528137205
Provider Name (Legal Business Name): 9128 COLUMBIA CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9128 COLUMBIA CORPORATION 9128 COLUMBIA AVENUE
MUNSTER IN
46321
US

IV. Provider business mailing address

9128 COLUMBIA CORPORATION 9128 COLUMBIA AVENUE
MUNSTER IN
46321
US

V. Phone/Fax

Practice location:
  • Phone: 219-836-2730
  • Fax: 219-836-0244
Mailing address:
  • Phone: 219-836-2730
  • Fax: 219-836-0244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0632560
License Number StateIN

VIII. Authorized Official

Name: AZRA S SHERIFF
Title or Position: PRESIDENT
Credential: MD
Phone: 219-836-2730