Basic Information
| Provider Information | |||||||||
| NPI: | 1013943109 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEPHROLOGY & INTERNAL MEDICINE, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | INDIANA KIDNEY INSTITUTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5510 S EAST ST STE H | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462271938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179248425 | ||||||||
| FaxNumber: | 3179248424 | ||||||||
| Practice Location | |||||||||
| Address1: | 5510 S EAST ST | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462271938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179248425 | ||||||||
| FaxNumber: | 3179248424 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BAIRD | ||||||||
| AuthorizedOfficialFirstName: | NANCY | ||||||||
| AuthorizedOfficialMiddleName: | REGINA | ||||||||
| AuthorizedOfficialTitleorPosition: | C.E.O. | ||||||||
| AuthorizedOfficialTelephone: | 3179248425 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 06/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | -001 | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 100061370 | 05 | IN | MEDICAID |