MEDICARE: DR. KOUROSH BAGHELAI M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2086S0129X	Vascular Surgery Physician	4301084433	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1366434987
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KOUROSH BAGHELAI M.D.

Provider Business Mailing Address
First Line	:	2500 NILES RD STE 6
Second Line	:
City	:	SAINT JOSEPH
State	:	MI
Zip	:	49085-3268
Country	:	US
Telephone Number	:	269-408-1660
Fax Number	:	269-408-1665

Provider Business Practice Location Address
First Line	:	2500 NILES RD STE 6
Second Line	:
City	:	SAINT JOSEPH
State	:	MI
Zip	:	49085-3268
Country	:	US
Telephone Number	:	269-408-1660
Fax Number	:	269-408-1665

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2005
Last Update Date	:	10/15/2012

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Directions to “ DR. KOUROSH BAGHELAI M.D.” Practice Location

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