Basic Information
| Provider Information | |||||||||
| NPI: | 1225284334 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHAIRI | ||||||||
| FirstName: | SHAFAQ | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3621 S STATE ST | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481081633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346475299 | ||||||||
| FaxNumber: | 9107383764 | ||||||||
| Practice Location | |||||||||
| Address1: | 4260 PLYMOUTH RD | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481092700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347646831 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2008 | ||||||||
| LastUpdateDate: | 02/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 2008-00363 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 4301109144 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RE0101X | 4301109144 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 5910700 | 05 | NC | MEDICAID | 1508J | 01 | NC | BCBS | OTHER |