Provider Demographics
NPI:1306893847
Name:KHOURY, BASEL (MD)
Entity type:Individual
Prefix:DR
First Name:BASEL
Middle Name:
Last Name:KHOURY
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 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-446-5890
Mailing Address - Fax:740-446-5532
Practice Address - Street 1:280 PATTONSVILLE RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:OH
Practice Address - Zip Code:45640-9452
Practice Address - Country:US
Practice Address - Phone:740-395-8805
Practice Address - Fax:740-395-8855
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-08-5785207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000181848OtherUNISON MEDICAID
OH2605569OtherMOLINA MEDICAID
P00274238OtherRR MEDICARE
000000370742OtherANTHEM BCBS
1306893847OtherNPI
001770630OtherMOUNTAIN STATE BCBS
WV3810002963Medicaid
1306893847OtherNPI
I46967Medicare UPIN