Basic Information
| Provider Information | |||||||||
| NPI: | 1326038142 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KHAIR | ||||||||
| FirstName: | SAM | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 EAGLE SPRING DR | ||||||||
| Address2: | |||||||||
| City: | STOCKBRIDGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302816328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702133366 | ||||||||
| FaxNumber: | 4049626943 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 EAGLE SPRING DR | ||||||||
| Address2: | |||||||||
| City: | STOCKBRIDGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302816328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702133366 | ||||||||
| FaxNumber: | 4049626943 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2005 | ||||||||
| LastUpdateDate: | 02/27/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35194 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7927 | 01 | GA | KAISER | OTHER | 0102000 | 01 | GA | UNITED HEALTHCARE | OTHER | 314129 | 01 | GA | WELLCARE | OTHER | 000486241F | 05 | GA | MEDICAID | 080039316 | 01 | GA | RAILROAD MEDICARE | OTHER | 52027054001 | 01 | GA | BC/BS GEORGIA | OTHER | 10033142 | 01 | GA | AMERIGROUP | OTHER | 1071040001 | 01 | GA | PEACHSTATE | OTHER |