Provider Demographics
NPI:1104842731
Name:KHREIM, IMAD M (MD)
Entity Type:Individual
Prefix:
First Name:IMAD
Middle Name:M
Last Name:KHREIM
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 1:40 WRIGHT ST
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:MA
Mailing Address - Zip Code:01069-1138
Mailing Address - Country:US
Mailing Address - Phone:413-283-7651
Mailing Address - Fax:413-284-5117
Practice Address - Street 1:40 WRIGHT ST
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:MA
Practice Address - Zip Code:01069-1138
Practice Address - Country:US
Practice Address - Phone:413-284-5285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA803682084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
983547OtherNETWORK HEALTH
MA0300040Medicaid
F23771Medicare UPIN
MA0300040Medicaid