Basic Information
| Provider Information | |||||||||
| NPI: | 1164780284 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHAN | ||||||||
| FirstName: | MUHAMMAD | ||||||||
| MiddleName: | OMER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 BOSTON MEDICAL CTR PL # 1 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021182908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174144929 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 BOSTON MEDICAL CTR PL # 1 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021182908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174144929 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2012 | ||||||||
| LastUpdateDate: | 02/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 264661 | MA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 11016464 | IN | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 291124865 | 01 | NY | DRIVING LICENSE | OTHER |