Provider Demographics
NPI:1881625895
Name:KHADR, HISHAM AHMED (MD)
Entity type:Individual
Prefix:
First Name:HISHAM
Middle Name:AHMED
Last Name:KHADR
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:PO BOX 820956
Mailing Address - Street 2:TEMPLE PHYSICIANS INC
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-0956
Mailing Address - Country:US
Mailing Address - Phone:800-777-2455
Mailing Address - Fax:610-617-6820
Practice Address - Street 1:2301 E ALLEGHENY AVE
Practice Address - Street 2:NORTHEASTERN HOSPITAL
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134-4427
Practice Address - Country:US
Practice Address - Phone:215-423-2376
Practice Address - Fax:215-634-4872
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD041099L207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011504880009Medicaid
PAF44579Medicare UPIN
PA409025Medicare ID - Type Unspecified