Healthcare Provider Details

I. General information

NPI: 1669477246
Provider Name (Legal Business Name): SAMRA KHURSHID M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 07/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2333 BIDDLE AVE HENRY FORD WYANDOTTE
WYANDOTTE MI
48192
US

IV. Provider business mailing address

4967 CROOKS RD STE 130
TROY MI
48098-5801
US

V. Phone/Fax

Practice location:
  • Phone: 734-464-0887
  • Fax: 734-402-0254
Mailing address:
  • Phone: 248-952-1601
  • Fax: 248-952-1614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301070792
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number4301070792
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: