Basic Information
| Provider Information | |||||||||
| NPI: | 1306893847 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHOURY | ||||||||
| FirstName: | BASEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 90 JACKSON PIKE | ||||||||
| Address2: | |||||||||
| City: | GALLIPOLIS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456311560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404465890 | ||||||||
| FaxNumber: | 7404465532 | ||||||||
| Practice Location | |||||||||
| Address1: | 280 PATTONSVILLE RD | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456409452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403958805 | ||||||||
| FaxNumber: | 7403958855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 08/30/2007 | ||||||||
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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 | 207R00000X | 35-08-5785 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000181848 | 01 | OH | UNISON MEDICAID | OTHER | 2605569 | 01 | OH | MOLINA MEDICAID | OTHER | P00274238 | 01 | RR MEDICARE | OTHER | 000000370742 | 01 | ANTHEM BCBS | OTHER | 1306893847 | 01 | NPI | OTHER | 001770630 | 01 | MOUNTAIN STATE BCBS | OTHER | 3810002963 | 05 | WV | MEDICAID |