Provider Demographics
NPI:1851415798
Name:KHOURY, HABIB JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:HABIB
Middle Name:JOSEPH
Last Name:KHOURY
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 1:20525 CENTER RIDGE RD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:ROCKY RIVER
Mailing Address - State:OH
Mailing Address - Zip Code:44116-3437
Mailing Address - Country:US
Mailing Address - Phone:440-895-5056
Mailing Address - Fax:
Practice Address - Street 1:25200 CENTER RIDGE RD
Practice Address - Street 2:#3300
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-4141
Practice Address - Country:US
Practice Address - Phone:440-331-3645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-17
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH88982208200000X, 2082S0099X, 2082S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and Neck
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000518761OtherANTHEM
3610861OtherASC MEDICARE GRP #
1780634279OtherGROUP NPI
9273172OtherMEDICARE PHY GROUP #
CA4511OtherRR MEDICARE GROUP #
341783789127OtherCARESOURCE
OH2741779Medicaid
D368301OtherMEDICARE GRP IND LAB
7619947OtherAETNA
OH2741779Medicaid