Healthcare Provider Details

I. General information

NPI: 1811481435
Provider Name (Legal Business Name): FAREEA KHALIQ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2018
Last Update Date: 11/15/2023
Certification Date: 11/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

261 MACK AVE
DETROIT MI
48201-2417
US

IV. Provider business mailing address

1400 VFW PKWY
WEST ROXBURY MA
02132-4927
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-1203
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P0004X
TaxonomySpinal Cord Injury Medicine Physician
License Number1015240
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number1811481435
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: