Healthcare Provider Details

I. General information

NPI: 1932147279
Provider Name (Legal Business Name): EDEM S AGAMAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 10/16/2020
Certification Date: 10/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 W CARPENTER ST 1ST FLOOR, CLINIC B
SPRINGFIELD IL
62702-4901
US

IV. Provider business mailing address

315 W CARPENTER ST PO BOX 19678
SPRINGFIELD IL
62702-4901
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-8000
  • Fax: 217-545-1141
Mailing address:
  • Phone: 217-545-8000
  • Fax: 217-545-1141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number036085000
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: