=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649142399
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AGEWELL MEDICAL GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2025
-----------------------------------------------------
Last Update Date | 11/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 142 W VERDUGO AVE
-----------------------------------------------------
City | BURBANK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91502-2132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-588-3705
-----------------------------------------------------
Fax | 818-588-3685
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 142 W VERDUGO AVE
-----------------------------------------------------
City | BURBANK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91502-2132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-588-3705
-----------------------------------------------------
Fax | 818-588-3685
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/MD
-----------------------------------------------------
Name | DR. BASEM FARAG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 818-588-3705
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------