Basic Information
| Provider Information | |||||||||
| NPI: | 1851415798 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHOURY | ||||||||
| FirstName: | HABIB | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20525 CENTER RIDGE RD | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | ROCKY RIVER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441163437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408955056 | ||||||||
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| Practice Location | |||||||||
| Address1: | 25200 CENTER RIDGE RD | ||||||||
| Address2: | #3300 | ||||||||
| City: | WESTLAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441454141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403313645 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2007 | ||||||||
| LastUpdateDate: | 06/14/2012 | ||||||||
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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 | 208200000X | 88982 | OH | Y | Allopathic & Osteopathic Physicians | Plastic Surgery | 2082S0099X | 88982 | OH | N | Allopathic & Osteopathic Physicians | Plastic Surgery | Plastic Surgery Within the Head and Neck | 2082S0105X | 88982 | OH | N | Allopathic & Osteopathic Physicians | Plastic Surgery | Surgery of the Hand |
ID Information
| ID | Type | State | Issuer | Description | 000000518761 | 01 | ANTHEM | OTHER | 3610861 | 01 | ASC MEDICARE GRP # | OTHER | 1780634279 | 01 | GROUP NPI | OTHER | 9273172 | 01 | MEDICARE PHY GROUP # | OTHER | CA4511 | 01 | RR MEDICARE GROUP # | OTHER | 341783789127 | 01 | CARESOURCE | OTHER | 2741779 | 05 | OH | MEDICAID | D368301 | 01 | MEDICARE GRP IND LAB | OTHER | 7619947 | 01 | AETNA | OTHER |