Healthcare Provider Details

I. General information

NPI: 1467680942
Provider Name (Legal Business Name): SAMER AJAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2009
Last Update Date: 06/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S LAKE PARK AVE STE 110
HOBART IN
46342-6638
US

IV. Provider business mailing address

405 WESSEX RD
VALPARAISO IN
46385-7716
US

V. Phone/Fax

Practice location:
  • Phone: 219-947-6017
  • Fax: 219-947-6018
Mailing address:
  • Phone: 219-309-9353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number01069863A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number01069863A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01069863A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: