Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207R00000X | Internist | 01048808 | IN |
Y | 111NI0900X | Internist | 01048808 | IN |
N | 207RI0200X | Infectious Disease | 01048808A | IN |
NPI | 1073503207 |
---|---|
Provider Name | Imad George Koj |
First Address | Terre Haute, IN 47802-3558 |
Second Address | Terre Haute, IN 47802-5710 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/10/2005 |
Last Update Date | 30/09/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000000389741 | ANTHEM PIN (01) | IN |
200230910 | (05) | IN |
G96265 | (02) | |
P00283648 | RAILROAD MEDICARE (01) | IN |