Basic Information
| Provider Information | |||||||||
| NPI: | 1730107178 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHALID | ||||||||
| FirstName: | MAHMOOD | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 77000 | ||||||||
| Address2: | DEPT 160901 | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482771609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488577515 | ||||||||
| FaxNumber: | 7346777407 | ||||||||
| Practice Location | |||||||||
| Address1: | 461 W HURON ST | ||||||||
| Address2: | |||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483411601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488577515 | ||||||||
| FaxNumber: | 2488577524 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 03/15/2011 | ||||||||
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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 | 2085R0202X | 035499 | MI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 2707671 | 05 | MI | MEDICAID | CI8050 | 01 | MI | MEDICARE RR GROUP | OTHER | 4626456 | 05 | MI | MEDICAID | 0E01133 | 01 | MI | BCBS OF MI GROUP | OTHER |