Basic Information
| Provider Information | |||||||||
| NPI: | 1790797918 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN INDIANA NEPHROLOGY AND HYPERTENSION INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 940 N MARR RD STE B | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472012610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123750272 | ||||||||
| FaxNumber: | 8123751093 | ||||||||
| Practice Location | |||||||||
| Address1: | 940 N MARR RD STE B | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472012610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123750272 | ||||||||
| FaxNumber: | 8123751093 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2006 | ||||||||
| LastUpdateDate: | 11/02/2020 | ||||||||
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| AuthorizedOfficialLastName: | PIKUS | ||||||||
| AuthorizedOfficialFirstName: | RUSSELL | ||||||||
| AuthorizedOfficialMiddleName: | JAMES | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8123750272 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 11/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 200423640 | 05 | IN | MEDICAID |