Healthcare Provider Details

I. General information

NPI: 1902675556
Provider Name (Legal Business Name): BLACKSTONE MEDICAL, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/25/2023
Last Update Date: 09/04/2025
Certification Date: 09/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

688 E VINE ST STE 16
MURRAY UT
84107-5541
US

IV. Provider business mailing address

688 E VINE ST STE 16
MURRAY UT
84107-5541
US

V. Phone/Fax

Practice location:
  • Phone: 801-688-0210
  • Fax:
Mailing address:
  • Phone: 801-509-9138
  • Fax: 801-797-0237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KHALID AMRO HARARAH
Title or Position: CEO/OWNER
Credential: MD
Phone: 801-688-0210