Provider Demographics
NPI:1285721514
Name:BRIKHO, BASEL (MD)
Entity type:Individual
Prefix:
First Name:BASEL
Middle Name:
Last Name:BRIKHO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18211 W 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:LATHRUP VILLAGE
Mailing Address - State:MI
Mailing Address - Zip Code:48076
Mailing Address - Country:US
Mailing Address - Phone:248-557-4443
Mailing Address - Fax:248-557-0573
Practice Address - Street 1:18211 W 12 MILE RD
Practice Address - Street 2:
Practice Address - City:LATHRUP VILLAGE
Practice Address - State:MI
Practice Address - Zip Code:48076
Practice Address - Country:US
Practice Address - Phone:248-557-4443
Practice Address - Fax:248-557-0573
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2017-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301061420208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIBB061420OtherLICENSE
MI4092397Medicaid
MI383461699OtherTAX ID
MI0M80540Medicare ID - Type Unspecified
MIG59665Medicare UPIN