Basic Information
| Provider Information | |||||||||
| NPI: | 1366434987 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAGHELAI | ||||||||
| FirstName: | KOUROSH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 NILES RD STE 6 | ||||||||
| Address2: | |||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490853268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694081660 | ||||||||
| FaxNumber: | 2694081665 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 NILES RD STE 6 | ||||||||
| Address2: | |||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490853268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694081660 | ||||||||
| FaxNumber: | 2694081665 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2005 | ||||||||
| LastUpdateDate: | 10/15/2012 | ||||||||
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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 | 2086S0129X | 4301084433 | MI | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 104638715 | 05 | MI | MEDICAID |