=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902675556
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLACKSTONE MEDICAL, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/25/2023
-----------------------------------------------------
Last Update Date | 09/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 688 E VINE ST STE 16
-----------------------------------------------------
City | MURRAY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84107-5541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-688-0210
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 688 E VINE ST STE 16
-----------------------------------------------------
City | MURRAY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84107-5541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-509-9138
-----------------------------------------------------
Fax | 801-797-0237
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/OWNER
-----------------------------------------------------
Name | DR. KHALID AMRO HARARAH
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 801-688-0210
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2083P0011X
-----------------------------------------------------
Taxonomy Name | Undersea and Hyperbaric Medicine (Preventive Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------