Provider Demographics
NPI:1386830651
Name:KHALED M SHUKAIRY MD PC
Entity Type:Organization
Organization Name:KHALED M SHUKAIRY MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KHALED
Authorized Official - Middle Name:M
Authorized Official - Last Name:SHUKAIRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-742-0225
Mailing Address - Street 1:1501 S CENTER RD
Mailing Address - Street 2:BLDG B
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48509-1731
Mailing Address - Country:US
Mailing Address - Phone:810-742-0225
Mailing Address - Fax:810-742-7990
Practice Address - Street 1:1501 S CENTER RD
Practice Address - Street 2:BLDG B
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48509-1731
Practice Address - Country:US
Practice Address - Phone:810-742-0225
Practice Address - Fax:810-742-7990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-20
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301037118207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2126594Medicaid
MI2126594Medicaid