Provider Demographics
NPI:1477115418
Name:KHERALLAH, SHOUQ
Entity type:Individual
Prefix:
First Name:SHOUQ
Middle Name:
Last Name:KHERALLAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 FORD PL STE 3A
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3450
Mailing Address - Country:US
Mailing Address - Phone:313-874-4806
Mailing Address - Fax:
Practice Address - Street 1:2800 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2610
Practice Address - Country:US
Practice Address - Phone:888-245-6424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-30
Last Update Date:2025-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301513934207RH0000X, 207RX0202X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine