Basic Information
| Provider Information | |||||||||
| NPI: | 1407815624 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KHAN | ||||||||
| FirstName: | ABDUL | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1941 VIRGINIA AVE | ||||||||
| Address2: | |||||||||
| City: | CONNERSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 47331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7658255131 | ||||||||
| FaxNumber: | 7658277733 | ||||||||
| Practice Location | |||||||||
| Address1: | 1941 VIRGINIA AVE | ||||||||
| Address2: | |||||||||
| City: | CONNERSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 47331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7658277708 | ||||||||
| FaxNumber: | 7658277728 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 01043420A | IN | X | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | 01043420A | IN | X | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 35560591100 | 01 | OH | BWC | OTHER |