Healthcare Provider Details

I. General information

NPI: 1265956957
Provider Name (Legal Business Name): KHADER HATEM HERZALLAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 E MICHIGAN AVE
LANSING MI
48912-1811
US

IV. Provider business mailing address

788 SERVICE RD RM B-301
EAST LANSING MI
48824-7013
US

V. Phone/Fax

Practice location:
  • Phone: 517-364-1000
  • Fax:
Mailing address:
  • Phone: 517-432-2404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301112880
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: