Provider Demographics
NPI:1245122142
Name:KHALIL, SAMERH M
Entity type:Individual
Prefix:
First Name:SAMERH
Middle Name:M
Last Name:KHALIL
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 1:742 BERGEN BLVD
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07657-1435
Mailing Address - Country:US
Mailing Address - Phone:973-454-0528
Mailing Address - Fax:973-454-0528
Practice Address - Street 1:742 BERGEN BLVD
Practice Address - Street 2:
Practice Address - City:RIDGEFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07657-1435
Practice Address - Country:US
Practice Address - Phone:973-454-0528
Practice Address - Fax:973-454-0528
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-16
Last Update Date:2025-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ884247942Medicaid