Basic Information
| Provider Information | |||||||||
| NPI: | 1568625168 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KHALIL | ||||||||
| FirstName: | ELAINE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GRANMAYEH | ||||||||
| OtherFirstName: | ELAINE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6431 FANNIN ST | ||||||||
| Address2: | MSB 2.132 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770301501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7135007626 | ||||||||
| FaxNumber: | 7135007639 | ||||||||
| Practice Location | |||||||||
| Address1: | 6431 FANNIN ST | ||||||||
| Address2: | MSB 2.132 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770301501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7135007626 | ||||||||
| FaxNumber: | 7135007639 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2008 | ||||||||
| LastUpdateDate: | 07/13/2009 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | M9403 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 8BX820 | 01 | TX | BCBSTX | OTHER | 195147703 | 05 | TX | MEDICAID | 8AS172 | 01 | TX | BCBS | OTHER |