MEDICARE: OMAR KHAYYAM JOHNSON HFA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251B00000X	Case Management Agency	14002332A	IN

General Provider Information

NPI Number	:	1245899186
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OMAR KHAYYAM JOHNSON HFA

Provider Business Mailing Address
First Line	:	2735 ROTHE LN
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46229-5517
Country	:	US
Telephone Number	:	317-540-4294
Fax Number	:	317-434-5908

Provider Business Practice Location Address
First Line	:	2735 ROTHE LN
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46229-5517
Country	:	US
Telephone Number	:	317-540-4294
Fax Number	:	317-434-5908

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/12/2019
Last Update Date	:	06/12/2019

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