Basic Information
| Provider Information | |||||||||
| NPI: | 1649442385 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHAN | ||||||||
| FirstName: | SAMEENA | ||||||||
| MiddleName: | WAHEED | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 E SWAN ST | ||||||||
| Address2: | |||||||||
| City: | CENTERVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370331446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9317293091 | ||||||||
| FaxNumber: | 9317290809 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 E SWAN ST | ||||||||
| Address2: | |||||||||
| City: | CENTERVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370331446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9317293091 | ||||||||
| FaxNumber: | 9317290809 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2008 | ||||||||
| LastUpdateDate: | 12/18/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 001615 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | MD43967 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1510125 | 05 | TN | MEDICAID | 3002528 | 01 | TN | MEDICARE PTAN | OTHER |