Basic Information
| Provider Information | |||||||||
| NPI: | 1417186578 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHALIL | ||||||||
| FirstName: | ALI | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1420 VICEROY DR | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752352208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143582300 | ||||||||
| FaxNumber: | 2145796941 | ||||||||
| Practice Location | |||||||||
| Address1: | 7777 FOREST LN STE C750 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752306889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143582300 | ||||||||
| FaxNumber: | 2145796989 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2009 | ||||||||
| LastUpdateDate: | 04/18/2019 | ||||||||
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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 | 207RN0300X | 63877 | WI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207R00000X | 125-057102 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RN0300X | R7504 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 390200000X | 11016442A | IN | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 1417186578 | 05 | WI | MEDICAID | K400217447 | 01 | WI | MEDICARE PTAN | OTHER |