Basic Information
Provider Information | |||||||||
NPI: | 1790949741 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KHAMBATTA | ||||||||
FirstName: | SHEREZADE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 50505 SCHOENHERR RD | ||||||||
Address2: | STE 320 | ||||||||
City: | SHELBY TOWNSHIP | ||||||||
State: | MI | ||||||||
PostalCode: | 483153141 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5865803062 | ||||||||
FaxNumber: | 5865803143 | ||||||||
Practice Location | |||||||||
Address1: | 1165 S LINDEN RD | ||||||||
Address2: |   | ||||||||
City: | FLINT | ||||||||
State: | MI | ||||||||
PostalCode: | 485323406 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8107325400 | ||||||||
FaxNumber: | 8107331624 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/17/2008 | ||||||||
LastUpdateDate: | 09/08/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 51965 | MN | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RI0011X | 5101019075 | MI | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
ID | Type | State | Issuer | Description | P00839001 | 01 | MN | RAILROAD MEDICARE | OTHER | 1790949741 | 05 | MI |   | MEDICAID | ENROLLED | 05 | MN |   | MEDICAID | ENROLLED | 05 | IA |   | MEDICAID |