Basic Information
| Provider Information | |||||||||
| NPI: | 1073503207 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOJ | ||||||||
| FirstName: | IMAD | ||||||||
| MiddleName: | GEORGE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2723 S 7TH ST | ||||||||
| Address2: | STE A | ||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478023558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122381730 | ||||||||
| FaxNumber: | 8122421565 | ||||||||
| Practice Location | |||||||||
| Address1: | 3903 S 7TH ST | ||||||||
| Address2: | STE 2E | ||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478025710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122357370 | ||||||||
| FaxNumber: | 8122357570 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2005 | ||||||||
| LastUpdateDate: | 09/30/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 01048808 | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207RI0200X | 01048808A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 200230910 | 05 | IN | MEDICAID | 000000389741 | 01 | IN | ANTHEM PIN | OTHER | P00283648 | 01 | IN | RAILROAD MEDICARE | OTHER |