Healthcare Provider Details

I. General information

NPI: 1275616005
Provider Name (Legal Business Name): IMRAN KAZEM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 02/18/2021
Certification Date: 02/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

253 SAGAMORE PKWY W
WEST LAFAYETTE IN
47906-1501
US

IV. Provider business mailing address

1200 W WHITE RIVER BLVD
MUNCIE IN
47303-4988
US

V. Phone/Fax

Practice location:
  • Phone: 765-448-8000
  • Fax:
Mailing address:
  • Phone: 877-668-5621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number36483
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number01063605A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: