| Cleanse Clinic Jeffersonville Llc | |
|
1700 State St New Albany IN 47150-4916 | |
| (812) 914-7038 | |
| (812) 748-6035 |
| Full Name | Cleanse Clinic Jeffersonville Llc |
|---|---|
| Speciality | Psychiatry & Neurology |
| Location | 1700 State St, New Albany, Indiana |
| Authorized Official Name and Position | Abdul G Buridi (CEO) |
| Authorized Official Contact | 5027735088 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Cleanse Clinic Jeffersonville Llc 720 W Broadway Ste 202 Louisville KY 40202-3245 Ph: (502) 561-0943 | Cleanse Clinic Jeffersonville Llc 1700 State St New Albany IN 47150-4916 Ph: (812) 914-7038 |
| NPI Number | 1942728472 |
|---|---|
| Provider Enumeration Date | 09/05/2017 |
| Last Update Date | 01/31/2024 |
| Certification Date | 01/31/2024 |
| Medicare PECOS PAC ID | 7315372430 |
|---|---|
| Medicare Enrollment ID | O20200120000574 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1942728472 | NPI | - | NPPES |
| 300008912 | Medicaid | IN |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 2084P0802X | Psychiatry & Neurology - Addiction Psychiatry | 1784-0-ASO (Indiana) | Primary |
| Provider Name | Syed Q Kazmi |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1487619888 PECOS PAC ID: 2567367790 Enrollment ID: I20040326000022 |
| Provider Name | Asad Ismail |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1144227026 PECOS PAC ID: 7214926195 Enrollment ID: I20040506001422 |
| Provider Name | Rosalind S Williams |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1417412404 PECOS PAC ID: 5597190082 Enrollment ID: I20200109002490 |
| Provider Name | Sarah Ann Thomas |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1629445705 PECOS PAC ID: 4486962693 Enrollment ID: I20210628000136 |
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