Provider Demographics
NPI:1902865454
Name:IMAM, KHALED
Entity Type:Individual
Prefix:
First Name:KHALED
Middle Name:
Last Name:IMAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 TOWN CENTER DR STE 203
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-1744
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3535 W 13 MILE RD
Practice Address - Street 2:STE. 108
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6710
Practice Address - Country:US
Practice Address - Phone:248-551-1756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301047866207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI110F376980OtherBCBSM
MI2947749Medicaid
MI2947749Medicaid
MI0N74270004Medicare PIN