Healthcare Provider Details

I. General information

NPI: 1619923455
Provider Name (Legal Business Name): KHALIL M NASRALLAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 07/18/2025
Certification Date: 07/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W GRAND BOULEVARD NULL
DETROIT MI
48267-9622
US

IV. Provider business mailing address

2837 US 41 WEST
MARQUETTE MI
49855-0220
US

V. Phone/Fax

Practice location:
  • Phone: 313-916-2000
  • Fax:
Mailing address:
  • Phone: 906-225-3964
  • Fax: 906-226-3875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number4301079672
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number4301079672
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License Number4301079672
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: