Healthcare Provider Details

I. General information

NPI: 1013215615
Provider Name (Legal Business Name): ALI SALAR KHALILI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2011
Last Update Date: 09/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11100 EUCLID AVE SUITE 737, MAIL STOP 6004
CLEVELAND OH
44106-1716
US

IV. Provider business mailing address

24701 EUCLID AVE 3RD FLOOR
EUCLID OH
44117-1714
US

V. Phone/Fax

Practice location:
  • Phone: 216-844-1765
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number57-018565
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: