Provider Demographics
NPI:1053305490
Name:GHALILI, KOUROSH C (MD)
Entity Type:Individual
Prefix:
First Name:KOUROSH
Middle Name:C
Last Name:GHALILI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3070 BRISTOL PIKE STE 2-106
Mailing Address - Street 2:
Mailing Address - City:BENSALEM
Mailing Address - State:PA
Mailing Address - Zip Code:19020-5357
Mailing Address - Country:US
Mailing Address - Phone:215-447-8612
Mailing Address - Fax:267-522-8209
Practice Address - Street 1:3070 BRISTOL PIKE STE 2-106
Practice Address - Street 2:
Practice Address - City:BENSALEM
Practice Address - State:PA
Practice Address - Zip Code:19020-5357
Practice Address - Country:US
Practice Address - Phone:215-447-8612
Practice Address - Fax:267-522-8209
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD429774208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1018398010001Medicaid
PA1018398010002Medicaid
PA1018398010001Medicaid
PA1018398010002Medicaid
F85921Medicare UPIN
PA107699ZCHMMedicare PIN