Provider Demographics
NPI:1205008141
Name:WISSAM KHOORY, MD,PC
Entity Type:Organization
Organization Name:WISSAM KHOORY, MD,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CORMIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-893-4490
Mailing Address - Street 1:20 HOPE AVE
Mailing Address - Street 2:SUITE G03
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-2721
Mailing Address - Country:US
Mailing Address - Phone:781-893-4490
Mailing Address - Fax:781-893-1030
Practice Address - Street 1:20 HOPE AVE
Practice Address - Street 2:SUITE G03
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-2721
Practice Address - Country:US
Practice Address - Phone:781-893-4490
Practice Address - Fax:781-893-1030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-01
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA153969207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
J18529OtherBLUE CROSS