Provider Demographics
NPI:1205025780
Name:AGAM ENTERPRISES, LLC
Entity Type:Organization
Organization Name:AGAM ENTERPRISES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AYMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GHONIEM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-320-7229
Mailing Address - Street 1:PO BOX 10675
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47801-0675
Mailing Address - Country:US
Mailing Address - Phone:812-320-7229
Mailing Address - Fax:812-299-0004
Practice Address - Street 1:938 SPRINGDALE LN
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-4586
Practice Address - Country:US
Practice Address - Phone:812-234-8261
Practice Address - Fax:812-234-8262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-19
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01056877A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200882990Medicaid
IN200882990Medicaid