Basic Information
| Provider Information | |||||||||
| NPI: | 1366472755 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANGHVI | ||||||||
| FirstName: | AMIT | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6920 POINTE INVERNESS WAY STE 200 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468047934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604793514 | ||||||||
| FaxNumber: | 2604793520 | ||||||||
| Practice Location | |||||||||
| Address1: | 7910 W JEFFERSON BLVD STE 120 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468044159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604357612 | ||||||||
| FaxNumber: | 2604794618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 09/29/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 01063177A | IN | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085N0700X | 01063177A | IN | Y | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology |
ID Information
| ID | Type | State | Issuer | Description | 1366472755 | 05 | MI | MEDICAID | 200863420 | 05 | IN | MEDICAID | 2801141 | 05 | OH | MEDICAID |