1821127564 NPI number — DR. CHARLES M KHALIL D.P.M.

Table of content: DR. CHARLES M KHALIL D.P.M. (NPI 1821127564)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821127564 NPI number — DR. CHARLES M KHALIL D.P.M.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KHALIL
Provider First Name:
CHARLES
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.P.M.
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:
1821127564
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22770 KELLY RD
Provider Second Line Business Mailing Address:
#3
Provider Business Mailing Address City Name:
EASTPOINTE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48021-2009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-447-4900
Provider Business Mailing Address Fax Number:
586-447-0024

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22770 KELLY RD
Provider Second Line Business Practice Location Address:
#3
Provider Business Practice Location Address City Name:
EASTPOINTE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48021-2009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-447-4900
Provider Business Practice Location Address Fax Number:
586-447-0024
Provider Enumeration Date:
03/05/2007

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: 213E00000X , with the licence number:  CK001653 , 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: CK001653 . This is a "LICENCE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 061549240 . This is a "TAX ID #" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4855050810 . This is a "BLUE CROSS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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