Provider Demographics
NPI:1649263377
Name:KHATIB, RIAD EL (MD)
Entity type:Individual
Prefix:
First Name:RIAD
Middle Name:EL
Last Name:KHATIB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MOUHAMMED
Other - Middle Name:RIAD
Other - Last Name:KHATIB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:19251 MACK AVE
Mailing Address - Street 2:SUITE 333
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2893
Mailing Address - Country:US
Mailing Address - Phone:313-343-7280
Mailing Address - Fax:313-343-7921
Practice Address - Street 1:19251 MACK AVE
Practice Address - Street 2:333
Practice Address - City:GROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236-2893
Practice Address - Country:US
Practice Address - Phone:313-343-7280
Practice Address - Fax:313-343-7921
Is Sole Proprietor?:No
Enumeration Date:2005-08-29
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301033531207RI0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0H20891OtherBLUE CROSS AND BLUE SHIELD OF MICHIGAN-GROUP PIN
MI0H20891OtherBLUE CROSS AND BLUE SHIELD OF MICHIGAN-GROUP PIN
MI0M71670Medicare PIN