=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588823066
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KHALIL AND USEN DPM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2008
-----------------------------------------------------
Last Update Date | 06/24/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24566 SOUTHFIELD RD
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48075-2711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-423-4220
-----------------------------------------------------
Fax | 248-423-4221
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1628 FORD AVE
-----------------------------------------------------
City | WAYANDOTTA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48192-2304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-423-4220
-----------------------------------------------------
Fax | 248-423-4221
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MOHAMMAD KHALIL
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 248-423-4220
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------