Provider Demographics
NPI:1578678140
Name:DR KHALIFA REDA PLLC
Entity Type:Organization
Organization Name:DR KHALIFA REDA PLLC
Other - Org Name:DR KHALIFA REDA PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REDA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHALIFA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-683-8050
Mailing Address - Street 1:1579 N JOHN DALY RD
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-4906
Mailing Address - Country:US
Mailing Address - Phone:248-683-8050
Mailing Address - Fax:248-683-8590
Practice Address - Street 1:950 N CASS LAKE RD
Practice Address - Street 2:SUITE 112
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-2370
Practice Address - Country:US
Practice Address - Phone:248-683-8050
Practice Address - Fax:248-683-8590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRK072714207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1396787586OtherIND NPI NUMBER
MI4757476Medicaid
MI1396787586OtherIND NPI NUMBER
MI0P19640Medicare ID - Type UnspecifiedMEDICARE