Basic Information
| Provider Information | |||||||||
| NPI: | 1205025780 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AGAM ENTERPRISES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10675 | ||||||||
| Address2: | |||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478010675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123207229 | ||||||||
| FaxNumber: | 8122990004 | ||||||||
| Practice Location | |||||||||
| Address1: | 938 SPRINGDALE LN | ||||||||
| Address2: | |||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478024586 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122348261 | ||||||||
| FaxNumber: | 8122348262 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2007 | ||||||||
| LastUpdateDate: | 05/22/2008 | ||||||||
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| AuthorizedOfficialLastName: | GHONIEM | ||||||||
| AuthorizedOfficialFirstName: | AYMAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8123207229 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 01056877A | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 200882990 | 05 | IN | MEDICAID |