Healthcare Provider Details

I. General information

NPI: 1760792311
Provider Name (Legal Business Name): ASGHAR KHAGHANI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2010
Last Update Date: 05/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 BARCLAY AVE NE SUITE 200
GRAND RAPIDS MI
49503-2556
US

IV. Provider business mailing address

100 MICHIGAN NE MC 845
GRAND RAPIDS MI
49503
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-2802
  • Fax: 616-391-8875
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number4301096725
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number4301096725
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: