Healthcare Provider Details

I. General information

NPI: 1992350813
Provider Name (Legal Business Name): AGILE HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2019
Last Update Date: 09/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6036 N 19TH AVE STE 502
PHOENIX AZ
85015-2143
US

IV. Provider business mailing address

6036 N 19TH AVE STE 502
PHOENIX AZ
85015-2143
US

V. Phone/Fax

Practice location:
  • Phone: 623-738-0193
  • Fax:
Mailing address:
  • Phone: 623-738-0193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: MHD KUSSAY SAMKARI
Title or Position: MD
Credential:
Phone: 602-741-5504