Basic Information
| Provider Information | |||||||||
| NPI: | 1538329982 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | QATTASH | ||||||||
| FirstName: | ISMAIL | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 MEMORIAL SQ STE 50 | ||||||||
| Address2: | |||||||||
| City: | GREENFIELD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461401357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174686257 | ||||||||
| FaxNumber: | 3174686268 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 MEMORIAL SQ STE 2200 | ||||||||
| Address2: | |||||||||
| City: | GREENFIELD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461401378 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174686257 | ||||||||
| FaxNumber: | 3174686268 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2008 | ||||||||
| LastUpdateDate: | 06/27/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 01081966A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RN0300X | 036-120417 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 1538329982 1 | 05 | IL | MEDICAID | 279500 | 01 | IL | MEDICARE GROUP | OTHER |