Provider Demographics
NPI:1134221625
Name:AL-KHERSAN, RAID HASHIM FADHIL (MD)
Entity type:Individual
Prefix:
First Name:RAID
Middle Name:HASHIM FADHIL
Last Name:AL-KHERSAN
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 1:26850 PROVIDENCE PKWY
Mailing Address - Street 2:SUITE 505
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48374-1213
Mailing Address - Country:US
Mailing Address - Phone:248-465-4163
Mailing Address - Fax:248-662-4411
Practice Address - Street 1:26850 PROVIDENCE PKWY
Practice Address - Street 2:SUITE 505
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48374-1213
Practice Address - Country:US
Practice Address - Phone:248-465-4163
Practice Address - Fax:248-662-4411
Is Sole Proprietor?:No
Enumeration Date:2006-09-04
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301072465207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4425538Medicaid
MI4425538Medicaid
MIB06000056Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER