Healthcare Provider Details

I. General information

NPI: 1184625774
Provider Name (Legal Business Name): SHERIF M ELASSAL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2005
Last Update Date: 03/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 CHESTER BLVD
RICHMOND IN
47374-2317
US

IV. Provider business mailing address

9011 N MERIDIAN ST SUITE 225
INDIANAPOLIS IN
46260-5378
US

V. Phone/Fax

Practice location:
  • Phone: 765-962-4735
  • Fax: 765-939-0035
Mailing address:
  • Phone: 317-574-4747
  • Fax: 317-574-4737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number01052996
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: