Provider Demographics
NPI:1124080015
Name:KHALIL, MICHAEL ROUSHDY (MD, FACS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ROUSHDY
Last Name:KHALIL
Suffix:
Gender:M
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1216 VIA CORONEL
Mailing Address - Street 2:
Mailing Address - City:PALOS VERDES ESTATES
Mailing Address - State:CA
Mailing Address - Zip Code:90274-1992
Mailing Address - Country:US
Mailing Address - Phone:585-748-2080
Mailing Address - Fax:
Practice Address - Street 1:505 GOPHER DR
Practice Address - Street 2:
Practice Address - City:TOMAH
Practice Address - State:WI
Practice Address - Zip Code:54660-4513
Practice Address - Country:US
Practice Address - Phone:608-372-2181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA67078208600000X
ORMD178526208600000X
TN69129208600000X
ND14069208600000X
WI77985208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A670780Medicare ID - Type Unspecified
CAG89389Medicare UPIN