Basic Information
| Provider Information | |||||||||
| NPI: | 1790985596 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHAHAM | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | D.O., RPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3998 FAIR RIDGE DR. | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220332921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7032959360 | ||||||||
| FaxNumber: | 7037669725 | ||||||||
| Practice Location | |||||||||
| Address1: | 585 SCHENECTADY AVE | ||||||||
| Address2: | ANESTHESIA DEPT. | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112031851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186045207 | ||||||||
| FaxNumber: | 7186045571 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2007 | ||||||||
| LastUpdateDate: | 01/26/2015 | ||||||||
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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 | 183500000X | 047086 | NY | N | Pharmacy Service Providers | Pharmacist | 207L00000X | 246571 | NY | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 03224297 | 05 | NY | MEDICAID |