MEDICARE: SAMRA KHURSHID M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	4301070792	MI
2	208M00000X	Hospitalist Physician	4301070792	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	SK070792	OTHER	MI	BCBSM
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	70-0-F32947-0	OTHER	MI	BCBS CPIN #

General Provider Information

NPI Number	:	1669477246
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMRA KHURSHID M.D.

Provider Business Mailing Address
First Line	:	4967 CROOKS RD
Second Line	:	STE 130
City	:	TROY
State	:	MI
Zip	:	48098-5801
Country	:	US
Telephone Number	:	248-952-1601
Fax Number	:	248-952-1614

Provider Business Practice Location Address
First Line	:	2333 BIDDLE AVE
Second Line	:	HENRY FORD WYANDOTTE
City	:	WYANDOTTE
State	:	MI
Zip	:	48192
Country	:	US
Telephone Number	:	734-464-0887
Fax Number	:	734-402-0254

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/20/2005
Last Update Date	:	07/28/2015

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