Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208G00000X | Cardiothoracic Vascular Surgeon | MD429774 | PA |
NPI | 1053305490 |
---|---|
Provider Name | Kourosh C Ghalili |
First Address | Bensalem, PA 19020-5357 |
Second Address | Bensalem, PA 19020-5357 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/08/2005 |
Last Update Date | 26/12/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1018398010001 | (05) | PA |
1018398010002 | (05) | PA |
F85921 | (02) |