Provider Demographics
NPI:1144271206
Name:KHAYAL, HOSAM N (MD)
Entity type:Individual
Prefix:
First Name:HOSAM
Middle Name:N
Last Name:KHAYAL
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 1:1800 E LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-3810
Mailing Address - Country:US
Mailing Address - Phone:217-464-5811
Mailing Address - Fax:217-464-1318
Practice Address - Street 1:1915 LAKE AVE
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-9366
Practice Address - Country:US
Practice Address - Phone:574-948-4000
Practice Address - Fax:574-948-5454
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01065886A208M00000X, 207R00000X
IL036113434208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036113434Medicaid
IN000000883080OtherANTHEM
IN200926870Medicaid
IN000000612789OtherANTHEM
IN000000612789OtherBCBS
IL036113434Medicaid
ILK26143Medicare ID - Type UnspecifiedFEE SCHEDULE LOCALITY 16
IN941050ZZZMedicare PIN