Basic Information
| Provider Information | |||||||||
| NPI: | 1235133869 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHERVU | ||||||||
| FirstName: | INDIRA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 55 WHITCHER ST NE | ||||||||
| Address2: | STE 460 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601171 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704277389 | ||||||||
| FaxNumber: | 7704272845 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 WHITCHER ST NE | ||||||||
| Address2: | STE 460 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601171 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704277389 | ||||||||
| FaxNumber: | 7704272845 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2005 | ||||||||
| LastUpdateDate: | 08/01/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | GA040032 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 174400000X | 040032 | GA | N | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 000665706D | 05 | GA | MEDICAID | 000665706G | 05 | GA | MEDICAID | 000665706H | 05 | GA | MEDICAID | 000665706I | 05 | GA | MEDICAID | 000665706B | 05 | GA | MEDICAID | 000665706J | 05 | GA | MEDICAID | 000665706L | 05 | GA | MEDICAID | 000665706T | 05 | GA | MEDICAID | 000665706E | 05 | GA | MEDICAID | 000665706Q | 05 | GA | MEDICAID | 00665706A | 05 | GA | MEDICAID | 000665706R | 05 | GA | MEDICAID | 000665706C | 05 | GA | MEDICAID | 000665706K | 05 | GA | MEDICAID | 000665706O | 05 | GA | MEDICAID | 000665706N | 05 | GA | MEDICAID |