Healthcare Provider Details

I. General information

NPI: 1043798879
Provider Name (Legal Business Name): HUSAM ALDEAN KHALEEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2018
Last Update Date: 08/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5303 S CEDAR ST STE 205
LANSING MI
48911-5303
US

IV. Provider business mailing address

5303 S. CEDAR ST SUITE 205
LANSING MI
48911
US

V. Phone/Fax

Practice location:
  • Phone: 517-887-4305
  • Fax:
Mailing address:
  • Phone: 517-887-4305
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301115597
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: