Healthcare Provider Details

I. General information

NPI: 1972690634
Provider Name (Legal Business Name): SHERIF ELMASRY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 01/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 N BROADWAY
PERU IN
46970
US

IV. Provider business mailing address

655 N BROADWAY
PERU IN
46970
US

V. Phone/Fax

Practice location:
  • Phone: 765-475-0024
  • Fax: 765-475-0736
Mailing address:
  • Phone: 765-475-0024
  • Fax: 765-475-0736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01045850A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: