Provider Demographics
NPI:1043471436
Name:KHAIRI, TALAL R (MD)
Entity type:Individual
Prefix:
First Name:TALAL
Middle Name:R
Last Name:KHAIRI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5650 N GREEN BAY AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-4447
Mailing Address - Country:US
Mailing Address - Phone:414-431-5971
Mailing Address - Fax:414-434-0354
Practice Address - Street 1:5650 N GREEN BAY AVE STE 210
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53209-4447
Practice Address - Country:US
Practice Address - Phone:414-431-5971
Practice Address - Fax:414-434-0354
Is Sole Proprietor?:No
Enumeration Date:2008-06-19
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI64355207RN0300X, 208M00000X
MA236726208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI10045943Medicaid
WI1043471436Medicaid
000633001Medicare PIN