Provider Demographics
NPI:1619923455
Name:NASRALLAH, KHALIL M (MD)
Entity Type:Individual
Prefix:
First Name:KHALIL
Middle Name:M
Last Name:NASRALLAH
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 1:2837 US 41 WEST
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-0220
Mailing Address - Country:US
Mailing Address - Phone:906-225-3964
Mailing Address - Fax:906-226-3875
Practice Address - Street 1:N10561 GRANDVIEW LN
Practice Address - Street 2:
Practice Address - City:IRONWOOD
Practice Address - State:MI
Practice Address - Zip Code:49938-9622
Practice Address - Country:US
Practice Address - Phone:906-932-2290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010796722084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI130E26028OtherBLUE CROSS BLUE SHIELD MI
WI34726200OtherWISCONSIN MEDICAID
MI4877920Medicaid
MI130E26028OtherBLUE CROSS BLUE SHIELD MI
MI4877920Medicaid
MI0E26028011Medicare PIN