Healthcare Provider Details

I. General information

NPI: 1720438245
Provider Name (Legal Business Name): MAGED D. FAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2016
Last Update Date: 07/29/2025
Certification Date: 07/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIVERSITY OF KENTUCKY MEDICAL CENTER 800 ROSE STREET, MN 256
LEXINGTON KY
40536
US

IV. Provider business mailing address

9425 S MADISON ST
BURR RIDGE IL
60527-6850
US

V. Phone/Fax

Practice location:
  • Phone: 859-218-0097
  • Fax: 804-828-8300
Mailing address:
  • Phone: 732-514-6247
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036.164765
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberR-10566
License Number StateIA
# 3
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number036.164765
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: