=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396058442
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALKHERSAN PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2010
-----------------------------------------------------
Last Update Date | 12/23/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17327 STONEBROOK DR
-----------------------------------------------------
City | NORTHVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48168-4325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-849-4226
-----------------------------------------------------
Fax | 248-849-4240
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17327 STONEBROOK DR
-----------------------------------------------------
City | NORTHVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48168-4325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-849-4226
-----------------------------------------------------
Fax | 248-849-4240
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | RAID AL-KHERSAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 248-849-4226
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------