Basic Information
| Provider Information | |||||||||
| NPI: | 1881625895 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHADR | ||||||||
| FirstName: | HISHAM | ||||||||
| MiddleName: | AHMED | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 820956 | ||||||||
| Address2: | TEMPLE PHYSICIANS INC | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191820956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007772455 | ||||||||
| FaxNumber: | 6106176820 | ||||||||
| Practice Location | |||||||||
| Address1: | 2301 E ALLEGHENY AVE | ||||||||
| Address2: | NORTHEASTERN HOSPITAL | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191344427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154232376 | ||||||||
| FaxNumber: | 2156344872 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 01/12/2015 | ||||||||
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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 | 207P00000X | MD041099L | PA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207R00000X | MD041099L | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0011504880009 | 05 | PA | MEDICAID |