Basic Information
| Provider Information | |||||||||
| NPI: | 1871530105 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AGEE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4777 | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474024777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123361690 | ||||||||
| FaxNumber: | 8123491311 | ||||||||
| Practice Location | |||||||||
| Address1: | 814 LAPORTE AVE | ||||||||
| Address2: | |||||||||
| City: | VALPARAISO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463835860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123361690 | ||||||||
| FaxNumber: | 8123491311 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 12/03/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 02001176 | IN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02001176B | 01 | IN | CSR | OTHER | 100331050 | 05 | IN | MEDICAID | BA1676189 | 01 | DEA | OTHER | 02001176 | 01 | IN | INDIANA LICENSE | OTHER |