Provider Demographics
NPI:1891746228
Name:AMANU PHYSICAL MEDICINE & REHABILITATION, LLC
Entity Type:Organization
Organization Name:AMANU PHYSICAL MEDICINE & REHABILITATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ISMAILU
Authorized Official - Middle Name:O
Authorized Official - Last Name:AGBAJE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD MD
Authorized Official - Phone:812-272-4497
Mailing Address - Street 1:PO BOX 73200
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30271-3200
Mailing Address - Country:US
Mailing Address - Phone:812-272-4497
Mailing Address - Fax:419-828-8218
Practice Address - Street 1:2101 NEWNAN CROSSING BLVD E
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-2406
Practice Address - Country:US
Practice Address - Phone:812-272-4497
Practice Address - Fax:419-828-8218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV23966208100000X
208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000377504OtherANTHEM BCBS
OH085641552002OtherMEDICAL MUTUAL OF OHIO
OH2507317Medicaid
OHDE2205OtherRR MEDICARE PTAN
OH2507317Medicaid
OH=========OtherTAX ID
OH2507317Medicaid
OH085641552002OtherMEDICAL MUTUAL OF OHIO
OHDE2205OtherRR MEDICARE PTAN