1619959772 NPI number — MR. KIANOUSH KHAGHANY MD

Table of content: MR. KIANOUSH KHAGHANY MD (NPI 1619959772)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619959772 NPI number — MR. KIANOUSH KHAGHANY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KHAGHANY
Provider First Name:
KIANOUSH
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619959772
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/16/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1046 N MONROE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONROE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48162-3113
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-457-9034
Provider Business Mailing Address Fax Number:
734-457-9037

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1046 N MONROE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48162-3113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-457-9034
Provider Business Practice Location Address Fax Number:
734-457-9037
Provider Enumeration Date:
11/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  4301072919 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 104583009 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1605802182 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P00215065 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 04232 . This is a "PARAMOUNT" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 7626369 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1605802182 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 16945 . This is a "MCARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 20630 . This is a "HEALTHPLAN OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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