Basic Information
| Provider Information | |||||||||
| NPI: | 1124011473 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KHELLA | ||||||||
| FirstName: | SAMI | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3737 MARKET ST | ||||||||
| Address2: | 8TH FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191045545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156623606 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3737 MARKET ST | ||||||||
| Address2: | 8TH FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191045545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156623606 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2005 | ||||||||
| LastUpdateDate: | 08/20/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | MD034420E | PA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 06942 | 01 | HEALTH PARTNERS | OTHER | 1194992-01 | 05 | PA | MEDICAID | 0172208000 | 01 | KEYSTONE PLAN EAST | OTHER |