=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154492254
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GHAIDA KHODHER MD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/11/2006
-----------------------------------------------------
Last Update Date | 04/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2970 CROOKS RD SUITE A
-----------------------------------------------------
City | ROCHESTER HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48309-3609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-922-0680
-----------------------------------------------------
Fax | 248-922-2820
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2970 CROOKS RD SUITE A
-----------------------------------------------------
City | ROCHESTER HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48309-3609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-922-0680
-----------------------------------------------------
Fax | 248-922-2820
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | GHAIDA KHODHER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 248-922-0680
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RR0500X
-----------------------------------------------------
Taxonomy Name | Rheumatology Physician
-----------------------------------------------------
License Number | 4301068771
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------