=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205855418
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IMAD E. KHADRA MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2006
-----------------------------------------------------
Last Update Date | 05/08/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3920 ST FRANCIS WAY STE 220
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-502-4110
-----------------------------------------------------
Fax | 765-428-5951
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 781076
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48278-1076
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-528-4800
-----------------------------------------------------
Fax | 317-865-1479
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0200X
-----------------------------------------------------
Taxonomy Name | Critical Care Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | 01036728
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RP1001X
-----------------------------------------------------
Taxonomy Name | Pulmonary Disease Physician
-----------------------------------------------------
License Number | 01036728
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------