Healthcare Provider Details

I. General information

NPI: 1053305490
Provider Name (Legal Business Name): KOUROSH C GHALILI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 12/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3070 BRISTOL PIKE STE 2-106
BENSALEM PA
19020-5357
US

IV. Provider business mailing address

3070 BRISTOL PIKE STE 2-106
BENSALEM PA
19020-5357
US

V. Phone/Fax

Practice location:
  • Phone: 215-447-8612
  • Fax: 267-522-8209
Mailing address:
  • Phone: 215-447-8612
  • Fax: 267-522-8209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberMD429774
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: