Provider Demographics
NPI:1619923281
Name:INTERNAL MEDICINE & NEPHROLOGY ASSOCIATES, PC
Entity Type:Organization
Organization Name:INTERNAL MEDICINE & NEPHROLOGY ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:FAZEL
Authorized Official - Last Name:KHALILI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-340-4565
Mailing Address - Street 1:105 S BRYANT AVE
Mailing Address - Street 2:202
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-6399
Mailing Address - Country:US
Mailing Address - Phone:405-340-4565
Mailing Address - Fax:405-340-4583
Practice Address - Street 1:105 S BRYANT AVE
Practice Address - Street 2:202
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-6399
Practice Address - Country:US
Practice Address - Phone:405-340-4565
Practice Address - Fax:405-340-4583
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23879207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK342965190002OtherBLUE CROSS BLUE SHIELD
OK342965190002OtherBLUE CROSS BLUE SHIELD