Provider Demographics
NPI:1174700306
Name:AG CARDIOLOGY, INC
Entity type:Organization
Organization Name:AG CARDIOLOGY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ALI
Authorized Official - Middle Name:R
Authorized Official - Last Name:GHASEMZADEH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-378-9090
Mailing Address - Street 1:PO BOX 577
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45121-0577
Mailing Address - Country:US
Mailing Address - Phone:937-378-9090
Mailing Address - Fax:937-378-0102
Practice Address - Street 1:5062 STATE ROUTE 125
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:OH
Practice Address - Zip Code:45121-9561
Practice Address - Country:US
Practice Address - Phone:937-378-9090
Practice Address - Fax:937-378-0102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-30
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38551207RC0000X
OH35080480G207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2291738Medicaid
KY64073497Medicaid
KY9047Medicare PIN
OH9320381Medicare PIN
KY64073497Medicaid