Healthcare Provider Details

I. General information

NPI: 1558440925
Provider Name (Legal Business Name): HANI A KHOURY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 HAMBURG TPK SUITE 107
WAYNE NJ
07470
US

IV. Provider business mailing address

502 HAMBURG TPK SUITE 107
WAYNE NJ
07470
US

V. Phone/Fax

Practice location:
  • Phone: 973-942-6611
  • Fax: 973-942-5906
Mailing address:
  • Phone: 973-942-6611
  • Fax: 973-942-5906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number25MA03399800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: