Basic Information
| Provider Information | |||||||||
| NPI: | 1639286339 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GHALI | ||||||||
| FirstName: | FRED | ||||||||
| MiddleName: | ELIAS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1325 W. NORTHWEST HWY. | ||||||||
| Address2: | |||||||||
| City: | GRAPEVINE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760517524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174213376 | ||||||||
| FaxNumber: | 8174164269 | ||||||||
| Practice Location | |||||||||
| Address1: | 1325 W. NORTHWEST HWY | ||||||||
| Address2: | |||||||||
| City: | GRAPEVINE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760517524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174213376 | ||||||||
| FaxNumber: | 8174164269 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 174400000X | J7330 | TX | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 0033GU | 01 | TX | BCBS OF TEXAS | OTHER | 1899683 | 01 | TX | UNITED HEALTHCARE | OTHER | 7267016 | 01 | TX | AETNA | OTHER |