Basic Information
| Provider Information | |||||||||
| NPI: | 1831173541 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAHIRKHELI | ||||||||
| FirstName: | LAEEQ | ||||||||
| MiddleName: | AZMAT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | CAMERON REGIONAL MEDICAL CENTER, INC. | ||||||||
| Address2: | 1600 E EVERGREEN | ||||||||
| City: | CAMERON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 64429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8166322101 | ||||||||
| FaxNumber: | 8166493383 | ||||||||
| Practice Location | |||||||||
| Address1: | 214 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PLATTSBURG | ||||||||
| State: | MO | ||||||||
| PostalCode: | 644771238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8169302041 | ||||||||
| FaxNumber: | 8165392866 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2005 | ||||||||
| LastUpdateDate: | 08/10/2013 | ||||||||
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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 | 207R00000X | 2004019669 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 785D501 | 01 | MO | MEDICARE PART B | OTHER | 2004019669 | 01 | MO | CERTIFICATE/LICENSE NUMBE | OTHER | 243332046 | 05 | MO | MEDICAID | P00182717 | 01 | MO | MEDICARE RAILROAD | OTHER |