Healthcare Provider Details

I. General information

NPI: 1588871826
Provider Name (Legal Business Name): KHURSHAID ALAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 07/18/2023
Certification Date: 07/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4648 JOHN R ST JOHN DINGELL VA MEDICAL CENTER
DETROIT MI
48201-1916
US

IV. Provider business mailing address

4648 POND RUN
CANTON MI
48188-2198
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-3430
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4301085799
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2023013326
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number2023013326
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number4301085799
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: