Basic Information
| Provider Information | |||||||||
| NPI: | 1386758571 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AL-KHAFAJI | ||||||||
| FirstName: | BASIM | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5700 SOUTHWYCK BLVD | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436141509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002888325 | ||||||||
| FaxNumber: | 4198665453 | ||||||||
| Practice Location | |||||||||
| Address1: | 22101 MOROSS RD | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482362148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3133434000 | ||||||||
| FaxNumber: | 3138814727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2006 | ||||||||
| LastUpdateDate: | 12/21/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZC0500X | 071732 | MI | N | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZP0101X | 071732 | MI | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology |
ID Information
| ID | Type | State | Issuer | Description | 4618196 | 05 | MI | MEDICAID |