Basic Information
| Provider Information | |||||||||
| NPI: | 1730489790 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALLIANCE TELEMED LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2600 S HENDERSON ST | ||||||||
| Address2: | SUITE 122 | ||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474018439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123207229 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2600 S HENDERSON ST | ||||||||
| Address2: | SUITE 122 | ||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474018439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123207229 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2010 | ||||||||
| LastUpdateDate: | 11/25/2012 | ||||||||
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| AuthorizedOfficialLastName: | GHONIEM | ||||||||
| AuthorizedOfficialFirstName: | AYMAN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | SOLE MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 8123207229 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 01056877 | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.