Basic Information
| Provider Information | |||||||||
| NPI: | 1417968314 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHAN | ||||||||
| FirstName: | SHAHID | ||||||||
| MiddleName: | I | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2044 | ||||||||
| Address2: | DEPT 4300 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381012044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015076600 | ||||||||
| FaxNumber: | 9015076599 | ||||||||
| Practice Location | |||||||||
| Address1: | 1211 UNION AVE | ||||||||
| Address2: | STE 495 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381046656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015076600 | ||||||||
| FaxNumber: | 9015076599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 09/13/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | MD0000028889 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 246XC2901X | MD0000028889 | TN | N | Technologists, Technicians & Other Technical Service Providers | Spec/Tech, Cardiovascular | Cardiovascular Invasive Specialist |
ID Information
| ID | Type | State | Issuer | Description | 3723803 | 05 | TN | MEDICAID |