Healthcare Provider Details

I. General information

NPI: 1871557389
Provider Name (Legal Business Name): THARAYIL KHADEEJA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23077 GREENFIELD RD SUITE 253
SOUTHFIELD MI
48075-3709
US

IV. Provider business mailing address

8229 LAKE CREST DR
YPSILANTI MI
48197-6754
US

V. Phone/Fax

Practice location:
  • Phone: 248-559-5950
  • Fax: 248-559-2103
Mailing address:
  • Phone: 734-709-3750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301058445
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: