Provider Demographics
NPI:1346630803
Name:AGM IOP/PHP, LLC
Entity Type:Organization
Organization Name:AGM IOP/PHP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FRANCO
Authorized Official - Middle Name:
Authorized Official - Last Name:SICURO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-222-0602
Mailing Address - Street 1:10199 WOODFIELD LN
Mailing Address - Street 2:
Mailing Address - City:OLIVETTE
Mailing Address - State:MO
Mailing Address - Zip Code:63132-2922
Mailing Address - Country:US
Mailing Address - Phone:314-222-0602
Mailing Address - Fax:314-675-6681
Practice Address - Street 1:10199 WOODFIELD LN
Practice Address - Street 2:
Practice Address - City:OLIVETTE
Practice Address - State:MO
Practice Address - Zip Code:63132-2922
Practice Address - Country:US
Practice Address - Phone:314-282-2517
Practice Address - Fax:314-845-2798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-04
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOLC001426559261QM0850X, 261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder