Provider Demographics
NPI:1053311779
Name:AL KHATIB, YASSER (MD)
Entity Type:Individual
Prefix:
First Name:YASSER
Middle Name:
Last Name:AL KHATIB
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 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25 MICHIGAN ST NE STE 4200
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2559
Practice Address - Country:US
Practice Address - Phone:616-267-9150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301084773207RA0002X, 207RI0011X, 2080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
No207RA0002XAllopathic & Osteopathic PhysiciansInternal MedicineAdult Congenital Heart Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E16136Medicare UPIN
OH3556762OtherAETNA
2289689OtherBCMH
OH728292OtherBUCKEYE
OHP00411226OtherRAILROAD MEDICARE
OH000000221372OtherUNISON
OH2289689Medicaid
OH000000346159OtherANTHEM
OH04567OtherPARAMOUNT
OH1020746OtherUHC
OH363306OtherWELLCARE
OHAL4133283Medicare PIN
PA0011923520002OtherPA MEDICAID
MI4616594Medicaid