Basic Information
| Provider Information | |||||||||
| NPI: | 1588676811 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ADILI-KHAMS | ||||||||
| FirstName: | BABEK | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5183 | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393025183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017034282 | ||||||||
| FaxNumber: | 6017034597 | ||||||||
| Practice Location | |||||||||
| Address1: | 29101 HOSPITAL RD | ||||||||
| Address2: | |||||||||
| City: | LAKE ARROWHEAD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923529706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093369715 | ||||||||
| FaxNumber: | 9093365751 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2006 | ||||||||
| LastUpdateDate: | 02/12/2018 | ||||||||
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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 | 207Q00000X | 47390 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 502485400 | 05 | MN | MEDICAID | 20250 | 01 | MS | MS LICENSE | OTHER |